MP 4004b 01 07
Copyright, American Alternative Insurance Corporation, 2006
Page 1 of 2
ADOPTION AND FOSTER CARE PLACEMENT
AGENCY SUPPLEMENTAL APPLICATION
Named Insured: _
Name of Agency/Facility:
I. FOSTER PLACEMENT AGENCIES:
Important – Please attach: Copies of placement policy and procedures, family selection, training guidelines and any and
all applications used in the process.
1. What is the annual number of foster care placements? Current Year__
____________ Projected next year_____________
2. Average number of children being placed in fosters home?____________________ Group Home?__________________
3. Average age of children being placed in foster homes?_______________________ Group Home?__________________
4. What is the maximum number of children allowed per foster home? ______________________
5. How does this agency recruit foster homes?__________________________________________________________
6. Who licenses the foster homes?
Insured State Other please explain:_____________________________
7. Is insured legally responsible for the following:
Placement of children in homes? Yes No
Licensing of foster parents and homes? Yes No
Licensing of group homes if used?
Yes No
Supervision, Inspection and Home Checks? Yes No
Do contract or subcontract any of above ?
Yes No
o If yes please provide detailed explanation.
8. Does insured use any homes l
icensed by the
state? Yes No
If yes, does Insured re-interview and inspect homes prior to placement?
Yes No
If no, does Insured inspect home within 30 days of placement?
Yes No
9. Does insured receive prior placed children either from the state or private agencies?
Yes No
If yes, does Insured require complete history and case workers file prior to placing in another home?
Yes No
10. Does the insured have full immunity from the State? Yes No
If yes, please include a copy of state law regarding immunity.
If no, does insured have any immunity regarding foster care?
Yes No
If yes, please include copy of any state law regarding immunity and or explanation of liability.
11. Does insured have a hold harmless with the state/county/other foster care agency?
Yes No
12. How frequently are home inspections done?_____________, Are they scheduled or unscheduled?______________
13. Does home inspection include a consultation with foster child?
Yes No
If yes is consultation done
alone or group
14. Is your Foster Care program accredited?
Yes No If yes, what accreditation?______________________
Expiration Date:______________________________
15. Do Foster Families receive Orientation and Training?
Yes No
16. Do Foster Families receive full discloser with respect to child’s health history and related back ground?
Yes No
17. Is one foster parent required to stay at home and not seek outside employment?
Yes No
18. Does the acceptance procedure include background research and FBI checks?
Yes No
19. How often are children moved from one home to another? _____________________________
20. What is the percentage of children with disabilities (physical or mental)?___________________%
21. What percentage of children are removed from their parents’ home involuntarily?___________%
