Amynta EOB - ESO Application Amynta EOB (Ease of Business) ESO Application. Step 1 of 5 20% Qualifying Questions (Check All That Apply)Greater than 20% of Responders are Full Time Paid(Required) Yes No Department services a population greater than 25,000(Required) Yes No Department provides advanced emergency medical services(Required) Yes No Department doesn't have written bylaws(Required) Yes No Department provides Ambulance Services(Required) Yes No Are you a Professional/Trade Association(Required) Yes No Are you a Training Center(Required) Yes No If you have answered Yes to any of the above questions, our program is not the best fit for your Department and we will be unable to provide you with a quote.General Information (Please provide all requested information)Date of Application Month Day Year Date of Application Month Day Year Current CarrierLegal Name of the OrganizationMailing Address Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code FEINWebsitePrimary Contact Name First Last Primary contact email address Primary contact mobile phone numberRisk control name First Last Rick control email address Risk control mobile phone numberAre You Incorporated Yes No UnderwritingYear EstablishedType of OrganizationSelect OneIndependent DepartmentMunicipally OwnedTax DistrictType of DepartmentSelect OneVolunteer Fire Suppression OnlyBasic Rescue/EMSBasic Fire and Rescue/EMSAmbulance911 Dispatch CenterRelief AssociationPopulation of area served on a First Call basisOn a scale of 1 - 5, where 1 is the closest descriptor, does the following sentence describe your department: Our department is dedicated to serving our community by responding fast and aggressively to all emergencies believing every second saved may save a life.Select One12345If you answered the previous question with a 1 or 2, has your department ever experienced an intersection accident? Yes No If you answered the previous question with a 1 or 2, have any members ever had an intersection accident on a call? Yes No CensusNumber of Volunteers with EMS ExposureNumber of Full Time paid employees with EMS ExposureNumber of Volunteers without EMS ExposureNumber of Full Time paid employees with EMS ExposureNumber of Part Time paid employees with EMS ExposureNumber of Part Time paid employees without EMS ExposureNumber of publicly elected trusteesNumber of publicly elected commissionersNumber of publicly elected directorsNumber of publicly elected directorsEstimated Number of Annual ResponsesNumber of Fire and Non-Emergency RunsNumber of Emergency Medical RunsNumber of First Responder RunsFundingCurrent Year BudgetCurrent Year ExpensesCurrent Year Surplus/DeficitPrior Year BudgetPrior Year ExpensesPrior Year Surplus/DeficitProjected Next Year BudgetProjected Next Year BudgetProjected Next Year ExpensesProjected Next Year Surplus/DeficitAre all volunteers covered by workers compensation? Yes No If no, does your state mandate workers compensation be provided for volunteer fire department members and are you in compliance with the regulations? Yes No Are all paid employees covered by workers compensation? Yes No If no, does your state mandate workers compensation be provided for paid fire department members and are you in compliance with the regulations? Yes No Does the applicant have a comprehensive behavioral health program? Yes No Does the applicant have a mandatory lift policy? Yes No What is the highest level of EMS services provided?Select OneAdvanced Life SupportBasic Life SupportNo EMSStretcher QuestionsIndicate the type of stretcher straps used to secure patientsSelect OneN/A2 Point3 Point5 PointAre all bariatric patients transported using a bariatric cot? Yes No Are two transport teams used to transport all bariatric patients? Yes No Wheelchair QuestionsDo all wheelchairs meet WC 19 standards? Yes No Do all wheelchair tie-downs and lap belts meet WC 18 standards? Yes No Is a wheelchair checklist mandatory for all drivers to utilize? Yes No How often are wheelchair van drivers required to complete training?Select OneAnnuallyBi-AnnuallyRemedialOn a scale of 1-5 where 1 is the closest descriptor, how accurately does the following sentence describe your department: In our department the strong survive and arrive first on the scene.Select One12345If question 18 is a 1 or 2, how would you characterize your department?Select OneMachoWellness focusedEmployment Practices LiabilityEmployment Practices Liability/Management Liability (Select a Limit)Select One$300,000 Each Occurrence/$1,000,000 Aggregate$500,000 Each Occurrence/$1,000,000 Aggregate$1,000,000 Each Occurrence/$2,000,000 Aggregate$1,000,000 Each Occurrence/$3,000,000 Aggregate$1,000,000 Each Occurrence/$10,000,000 AggregateDoes the applicant have written policies in place, which are communicated and available to the workforce, for Dismissal? Yes No Does the applicant have written policies in place, which are communicated and available to the workforce, for Discrimination? Yes No Does the applicant have written policies in place, which are communicated and available to the workforce, for Performance Evaluation? Yes No Does the applicant have written policies in place, which are communicated and available to the workforce, for Sexual Harassment? Yes No Does the applicant have written policies in place, which are communicated and available to the workforce, for Discipline? Yes No Does the applicant have written policies in place, which are communicated and available to the workforce, for Promotions? Yes No Does the applicant have written policies in place, which are communicated and available to the workforce, for New Employee/Volunteer Orientation? Yes No Does the Applicant currently carry EPLI? Yes No If the Applicant carries coverage, are the limits at least $1,000,000? Yes No Is the coverage Claims Made or Occurrence? Yes No If the coverage is claims made, what is the retroactive date?Have the bylaws been reviewed by outside counsel? Yes No When were the bylaws last reviewed by outside counsel?Is a documented complaint resolution procedure in place and accessible to the workforce? Yes No On a scale of 1-5, where the best descriptor is 1, how close does the following sentence describe your department: we embrace arriving safely at the scene as a mission critical priority.Select One12345If you answered 4 or 5 to the question above, is arriving first on the scene more important than arriving safely? Yes No Does the applicant have a Junior Firefighter Program? Yes No If so, are background checks performed on the leaders of the program? Yes No Are there written rules for not being alone with junior members? Yes No CyberCyber Limit (Select a Limit)Select One$50,000$100,000Do you currently carry Cyber Insurance? Yes No If Yes, is it Claims Made or OccurrenceSelect OneClaims MadeOccurrenceIf it's Claims Made, what is the retroactive date?Do you have current firewall management software installed on all computers? Yes No Do you have current antivirus management software installed on your computer network? Yes No Do you have a written security and privacy policy? Yes No CrimeCrime (Select a Coverage)Select OneEmployee Dishonesty - Coverage Form A - BlanketEmployee Dishonesty - Coverage Form A - Name ScheduleEmployee Dishonesty - Coverage Form A - Position SchedulePublic Employee Dishonesty - Coverage Form O - Blanket Per LossPublic Employee Dishonesty - Coverage Form P - Blanket Per EmployeePublic Employee Dishonesty - Coverage Form P - Name SchedulePublic Employee Dishonesty - Coverage Form P - Position ScheduleSpecific Excess Limit of Insurance - Name Schedule (VCR303)Specific Excess Limit of Insurance - Position Schedule (VCR304)DeductibleSelect One$1,000$2,500$5,000$10,000Forgery/Alteration Yes No Computer Fraud Yes No Identity Fraud Expense Yes No List your covered entities Yes No Do purchases in excess of $300 require signed approval of two or more people? Yes No Do checks require two signatures when in excess of $300? Yes No Are bank accounts, credit cards and vendor payments reviewed monthly? Yes No Are bank accounts and credit card statements reconciled by someone not authorized to deposit, withdraw or use credit cards? Yes No Are you aware of any dishonest or criminal act committed by any of your members prior to completing this application, whether during the course of their membership or not? Yes No If you answered Yes to the previous question, is the offending party still a member of the department? Yes No Are the financial records audited by outside parties? Yes No Is the audit certified? Yes No General LiabilityGeneral Liability Limits (Select a Limit)Select One$300,000 Each Occurrence/$1,000,000 Aggregate$500,000 Each Occurrence/$1,000,000 Aggregate$1,000,000 Each Occurrence/$2,000,000 Aggregate$1,000,000 Each Occurrence/$3,000,000 Aggregate$1,000,000 Each Occurrence/$10,000,000 AggregateMed Pay LimitsSelect One$5,000$10,000Year Round Club at Station? Yes No If yes, Gross Receipts?If yes, is a License/Permit required by the State? Yes No If yes, choose which applies to your Sponsored EventsSelect OnePermits alcohol but doesn't sell itProvides bartenders to serve non-owned alcoholAlcohol prohibited at Sponsored EventsIs alcohol Sold or provided on premises? Yes No If alcohol is sold on premises, what are the gross alcohol receipts annually?Is safety training provided annually for all volunteers and employees? Yes No Do all areas of public assembly have emergency lighting? Yes No If no, will you be installing emergency lighting in all areas of public assembly in the next 24 months? Yes No Do you own or are you responsible for any above ground storage tanks? Yes No Does the applicant have a kitchen? Yes No If yes, does the Kitchen have an ANSUL system? Yes No If yes, is the Kitchen open to the public? Yes No How many days is the kitchen open to the public?Select One1 Day a Week2 Day a Week3 Day a Week4 Day a Week5 Day a Week6 Day a Week7 Day a WeekWhat types of special events are sponsored or held?Select OneSelect OneCarnivals or Field Days with Mechanical Amusement DevicesConventions SponsoredFireworksBingoMotorized Events (Tractor Pulls/Mud Bogs)Hall RentalsSporting Event or ExhibitionHow often is the kitchen used?1 Day a Week2 Day a Week3 Day a Week4 Day a Week5 Day a Week6 Day a Week7 Day a WeekIf you have carnivals, how many days annually?If you have carnivals, are they operated by a qualified contractor? Yes No If you have carnivals operated by a qualified contractor, are they carrying Liability limits of $1,000,000 or higher? Yes No If you have carnivals operated by a qualified contractor, have they named you as an additional insured? Yes No If you have carnivals operated by a qualified contractor, do you have a certificate of insurance naming you as an additional insured on file? Yes No If you have Conventions, what is the total number of days which are held?If you have Fireworks, how many days per year?If you have Fireworks, how many days per year?If you have Fireworks, are they detonated by an outside contractor? Yes No If you have BINGO, how many days annually?If you have Motorized Events (Tractor Pulls/Mud Bogs), how many days per year?If you rent your the Hall, how many days annually?Is the Property occupied 24 hours a day? Yes No AutomobileAutomobile Combined Single LimitSelect OneSelect One$300,000$500,000$1,00,000No Coverage DesiredComprehensive DeductibleSelect One$500$1,000$3,000$5,000Collision DeductibleSelect One$500$1,000$3,000$5,000Vehicle Types (click + icon to add more vehicles)Vehicle #YearMakeModelClassificationVINAgreed ValueOCNInternal Vehicle ID Add RemoveSelect Vehicle 1 Type:FVL (Fire Vehicle Light GVW 10,000 pounds or Less), FVM (Fire Vehicle Medium GVW 10,001 - 20,000 pounds), FVH (Fire Vehicle Heavy GVW 20,001 - 45,000 pounds), FVEH (Fire Vehicle Extra Heavy GVW over 45,000 pounds), FPPT (Fire PPT's), NFPPT (Non-Fire PPT's) A (Ambulances), SV (Service Vehicles - Non-ESO)Select OneFVLFVMFVHFVEHFPPTNFPPTASVSelect Vehicle 2 Type:FVL (Fire Vehicle Light GVW 10,000 pounds or Less), FVM (Fire Vehicle Medium GVW 10,001 - 20,000 pounds), FVH (Fire Vehicle Heavy GVW 20,001 - 45,000 pounds), FVEH (Fire Vehicle Extra Heavy GVW over 45,000 pounds), FPPT (Fire PPT's), NFPPT (Non-Fire PPT's) A (Ambulances), SV (Service Vehicles - Non-ESO)Select OneFVLFVMFVHFVEHFPPTNFPPTASVSelect Vehicle 3 Type:FVL (Fire Vehicle Light GVW 10,000 pounds or Less), FVM (Fire Vehicle Medium GVW 10,001 - 20,000 pounds), FVH (Fire Vehicle Heavy GVW 20,001 - 45,000 pounds), FVEH (Fire Vehicle Extra Heavy GVW over 45,000 pounds), FPPT (Fire PPT's), NFPPT (Non-Fire PPT's) A (Ambulances), SV (Service Vehicles - Non-ESO)Select OneSelect OneFVLFVMFVHFVEHFPPTNFPPTASVSelect Vehicle 4 Type:FVL (Fire Vehicle Light GVW 10,000 pounds or Less), FVM (Fire Vehicle Medium GVW 10,001 - 20,000 pounds), FVH (Fire Vehicle Heavy GVW 20,001 - 45,000 pounds), FVEH (Fire Vehicle Extra Heavy GVW over 45,000 pounds), FPPT (Fire PPT's), NFPPT (Non-Fire PPT's) A (Ambulances), SV (Service Vehicles - Non-ESO)Select OneFVLFVMFVHFVEHFPPTNFPPTASVSelect Vehicle 5 Type:FVL (Fire Vehicle Light GVW 10,000 pounds or Less), FVM (Fire Vehicle Medium GVW 10,001 - 20,000 pounds), FVH (Fire Vehicle Heavy GVW 20,001 - 45,000 pounds), FVEH (Fire Vehicle Extra Heavy GVW over 45,000 pounds), FPPT (Fire PPT's), NFPPT (Non-Fire PPT's) A (Ambulances), SV (Service Vehicles - Non-ESO)Select OneFVLFVMFVHFVEHFPPTNFPPTASVSelect Vehicle 6 Type:FVL (Fire Vehicle Light GVW 10,000 pounds or Less), FVM (Fire Vehicle Medium GVW 10,001 - 20,000 pounds), FVH (Fire Vehicle Heavy GVW 20,001 - 45,000 pounds), FVEH (Fire Vehicle Extra Heavy GVW over 45,000 pounds), FPPT (Fire PPT's), NFPPT (Non-Fire PPT's) A (Ambulances), SV (Service Vehicles - Non-ESO)Select OneFVLFVMFVHFVEHFPPTNFPPTASVQuestionsDo you want Rental Reimbursement Coverage? Yes No If yes for Rental Reimbursement Coverage, to which vehicles should it apply?Do you have any Garage exposure (such as vehicle repair for third parties)? Yes No If you have Garage exposure, do you charge for repair work to third party vehicles? Yes No If you have Garage exposure without doing repair work, do you want to elect coverage? Yes No If yes, please provide the address for where the Garage Liability will apply.Garage Keepers Legal Liability LimitSelect One$300,000$500,000$1,000,000No Coverage DesiredGarage Keepers Legal Liability Comprehensive DeductibleSelect One$500$1,000$3,000$5,000Garage Keepers Legal Liability Collision DeductibleSelect One$500$1,000$3,000$5,000Loss Payee Name, Address and Vehicle Number to which it AppliesHow many vehicles have been converted from previous use?Which vehicles have had a water tank installed?Does the Applicant have a comprehensive and documented Emergency Vehicle Operations Program? Yes No Does the applicant evaluate the overall health of all emergency vehicle drivers/operators? Yes No How often are the drivers evaluated?Select OneAnnuallyEvery Two YearsEvery Three Years Property and EquipmentPropertyProperty Coverage Type:Select OneBlanketScheduledNoneDeductible?Select One$250$500$1,000$2,500Property Information (Click the + to add more locations)Location #Street AddressCityStateZipCounty Add RemoveProperty Status (Click the + to add more locations)Location #Occupied AsBuilding ValueContents ValueYear BuiltConstruction CodeSprinkler SystemIf Yes, Is there a quarterly test on 2 inch drainBuilding Square FootageProtection ClassElectrical Updated? (Year of Update)Roof Inspected last 12 monthsOccupied 24 HoursSleeping AccommodationsComprehensive self-inspection survey to document condition of the building(s) and grounds? Add RemoveNotesProperty Mortgage (Click the + to add more locations)Location #Mortgagee NameMortgagee Address (Street, City, State, ZipLoss Payee NameLoss Payee Address (Street, City, State, Zip) Add RemovePortable Equipment CoverageCoverage TypeSelect OneBlanketScheduledNoneDeductibleSelect One$250$500$1,000$2,500$5,000Blanket LimitPortable Equipment (Click the + to add more)Item #DescriptionSerial NumberQuantityTotal Value Add RemoveSearch and Rescue DogSearch and Rescue Dog (Choose One) Yes No Search and Rescue Dog (Click the + to add more)BreedSexYear of BirthNameValue Add RemoveDrone CoverageDrone Coverage (Choose One) Yes No Drone Information (Click the + to add more)ModelSerial NumberDrone Weight (in pounds)Drone ValueValue of Equipment Attached to Drone? Add RemoveAre Drone operations conducted in accordance with FAA rules? Yes No How many personnel are authorized to use drones?How many hours of training are required before personnel are authorized to operate drones?Does the applicant have written policies and procedures addressing storage and accessibility to the drone by qualified operators? Yes No Does the organization loan, rent or lease your drones? Yes No If yes, please describe to whom.If yes, is there an executed contract between both parties? Yes No If yes, is the Applicant held harmless by the third party? Yes No Excess LiabilityWhich Excess Liability Limit Is Desired?Select One$1,000,000$2,000,000$3,000,000$5,000,000No Coverage DesiredLosses - Please list belowCurrent YearCurrent Year (Specify Date Range)AutomobileGeneral / Professional LiabilityEmployment Practices/Management LiabilityCrimeCyberInland Marine / EquipmentPrior YearPrior Year (Specify Date Range)AutomobileGeneral / Professional LiabilityEmployment Practices/Management LiabilityCrimeCyberInland Marine / EquipmentPrior YearPrior Year (Specify Date Range)AutomobileGeneral / Professional LiabilityEmployment Practices/Management LiabilityCrimeCyberInland Marine / Equipment Add RemovePrior YearPrior Year (Specify Date Range)AutomobileGeneral / Professional LiabilityEmployment Practices/Management LiabilityCrimeCyberInland Marine / Equipment Add Remove