Teen Challenge Survey - Emery & Webb Insurance for Churches

Contact Information
Name of Teen Challenge Center*
Address of Teen Challenge Center*
Street Address Address Line 2 City State ZIP Code
Contact Name*
Prefix First Last
Contact Phone Number*
Contact Email*

Insurance
Approximately how many times a year do you interact with your insurance agent or risk manager?
Please rate your satisfactions with your current insurance program in regards to Annual Pricing
- Very Satisfied
- Satisfied
- Neutral
- Unsatisfied
- Very Unsatisfied
Please rate your satisfaction with your current insurance program in regards to answering your questions
- Very Satisfied
- Satisfied
- Neutral
- Unsatisfied
- Very Unsatisfied
Please rate your satisfaction with your current insurance program in regards to quickness of response
- Very Satisfied
- Satisfied
- Neutral
- Unsatisfied
- Very Unsatisfied
Would you be interested in switching insurance companies if it reduced costs and improved your understanding of safety and protection of the ministry?
Would you be willing to switch insurance agents to obtain a program that reduced costs and improved your understanding of safety and protection of the ministry?
What are the insurance companies used and the approximate annual costs for your following policies?
Worker's Compensation
Company Annual Cost
Automobile
Company Annual Cost
Package (General Liability, Property, Professional, Crime)
Company Annual Cost
Directors & Officers
Company Annual Cost
Umbrella
Company Annual Cost
Approximate Annual Operating Budget

Board of Directors / Leadership
How many people serve on your Board of Directors?
# Female # Male
Do you currently have the appropriate number of trustees so that you are in compliance with your Constitution and Bylaws?
Does the board of directors commission a committee that has risk management as its purpose?
Are both federal and state criminal background checks conducted on all staff and students?
Have all staff been given written job descriptions or job portfolios?
Are the formal complaint procedures supplied and explained to all students and staff?
Is there a formal response plan communicated to all staff and students for the following:
Fire
Extreme Weather
Active Shooter
Physical Altercations
Medical Emergencies
Are students involved in any of the following work for the center or as work teams on behalf of the center:
Kitchen/ Food Preparation
Landscaping
Roofing
Janitorial
Snow Removal
Carpentry
Other
Do you have any of the following professionals on staff or contracted? If yes, please provide the approximate number. If no, please leave blank.
Pastoral counselors - licensed
# Employees # Contracted
Pastoral counselors - un-licensed
# Employees # Contracted
Educationally qualified counselors (M.A., MSW, Etc.) - licensed
# Employees # Contracted
Un-licensed counselors
# Employees # Contracted
Un-licensed counselors
# Employees # Contracted
LPN's
# Employee # Contracted
RN's
# Employee # Contracted
Psychiatrists
# Employee # Contracted
Psychologists
# Employee # Contracted
Social Workers
# Employee # Contracted
Physicians
# Employee # Contracted
Nurse Practitioner
# Employee # Contracted

Campus
Is there a designated part of the operating budget allocated to improving the physical campuses?
Is there at least one staff member who has the responsibility of maintenance and improvement of the campus as part of their written job description?
Please provide the number of locations and information about each
Name or Description of location Street Address City, State, Zip # of Students # of Staff

Please provide information regarding each of your locations including a brief description, i.e. soup kitchen, residential center, thrift store, etc.
Do all dormitories have the following:
Sprinklers
Fire Extinguishers
Central Station Fire Alarm
Central Station Burglar Alarm
Illuminated Exit Signs
What part of the campus needs the most attention in regards to maintenance?

Auto:
Approximate # of vehicles owned by the center
Are Motor Vehicle Reports obtained for all staff prior to allowing them to drive vehicles?
Is formal driving training supplied to all staff before they are allowed to drive vehicles on the organization’s behalf?
Do you have a formal re-training policy for staff after they have had an accident?
Do you have a formal maintenance schedule for the organization’s vehicles?
Is the maintenance of the vehicles a written responsibility within a certain staff member’s job description?

Comments & Feedback
What insurance or risk management issue is the most frustrating to you?
What insurance or risk management issue do you wish you had more guidance or help with?
List

Name or Description of location	Street Address	City, State, Zip	# of Students	# of Staff

Company	Annual Cost

Company	Annual Cost

Company	Annual Cost

Company	Annual Cost

Step 1 of 6 - Contact

Contact Information

Insurance

What are the insurance companies used and the approximate annual costs for your following policies?

Board of Directors / Leadership

Is there a formal response plan communicated to all staff and students for the following:

Are students involved in any of the following work for the center or as work teams on behalf of the center:

Do you have any of the following professionals on staff or contracted? If yes, please provide the approximate number. If no, please leave blank.

Campus

Do all dormitories have the following:

Auto:

Comments & Feedback