SAM Liability Insurance

If you would like Jeama to investigate SAM liability insurance for you, please follow this link to jigsawrisk.com. Jigsaw is a DBA of Jeama that specializes in sexual abuse risk management.

Jigsaw expects to be able to find coverage for about 95% of applicants using the information they’ll request from you.

Jeama SAM Insurance Application

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Step 1 of 6

How many individuals fall into each category below?

Can or do work with minors or vulnerable adults

Should not work with minors or vulnerable adults

You should include all employees, all contractors, all forms of consultant, and all volunteers who work for or with the applicant in this calculation. Someone who can or does work with minors or vulnerable adults is someone applicant foresees will work regularly or occasionally with minors or vulnerable adults. Someone who should not work with minors or vulnerable adults is someone the applicant doesn't foresee ever working with minors or vulnerable adults.

How many individuals in each category below are male?

Can or do work with minors or vulnerable adults

Should not work with minors or vulnerable adults

What is the annual employee turnover rate?

Provide total headcount of all individuals who have worked with or for the applicant in each of the last five years

-1

-2

-3

-4

-5

How many individuals currently fall into each of the following categories:

Teachers

Substitute teachers

Coaches

Counsellors

Religious staff

Office staff

Volunteers

Other

Include full-time, part-time, employed, contracted, and volunteers.

Describe 'other'

How many individuals in each of the following categories are male:

Teachers

Substitute teachers

Coaches

Counselors

Religious staff

Office staff

Volunteers

Other

Include full-time, part-time, employed, contracted, and volunteers.

How many individuals fall into each of the following categories:

Doctors

Physician assistants

Nurses

Counsellors

Office staff

Volunteers

Other

Include full-time, part-time, employed, contracted, and volunteers.

Describe 'other'

How many individuals in each of the following categories are male:

Doctors

Physician assistants

Nurses

Counsellors

Office staff

Volunteers

Other

Include full-time, part-time, employed, contracted, and volunteers.

How many individuals fall into the following categories:

Corporate staff

Drivers

Volunteers

How many individuals in the following categories are male:

Corporate staff

Drivers

Volunteers

How many individuals fall into the following categories:

Priests or clergy

Coaches

Counsellors

Office staff

Missionaries (outside of domicile)

Foreign missionaries (visitors)

Volunteers

Other

Describe 'other'

How many individuals in the following categories are male:

Priests or clergy

Coaches

Counsellors

Office staff

Missionaries (outside of domicile)

Foreign missionaries (visitors)

Volunteers

Other

How many individuals fall into each of the following categories:

Doctors

Physician assistants

Nurses

Office staff

Volunteers

Other

Include full-time, part-time, employed, contracted, and volunteers.

Describe 'other'

How many individuals in each of the following categories are male:

Doctors

Physician assistants

Nurses

Office staff

Volunteers

Other

Include full-time, part-time, employed, contracted, and volunteers.

How many individuals fall into each of the following categories:

Doctors

Nurses

Office staff

Counselors or therapists

Coaches

Masseurs

Volunteers

Other

Include full-time, part-time, employed, contracted, and volunteers.

Describe 'other'

How many individuals in each of the following categories are male:

Doctors

Nurses

Office staff

Counselors or therapists

Coaches

Masseurs

Volunteers

Other

Include full-time, part-time, employed, contracted, and volunteers.

Has any applicant ever cancelled, been cancelled, non-renewed or been non-renewed for this type of coverage?

Yes

Provide full details of the cancellation or non-renewal

Do you currently have SAM insurance?

Yes

Who is your current insurer?

What is your current SAM limit of cover?

Which form of SAM do you have now?

Claims made

Occurrence

What is the current retroactive date?

Please up-load a copy of your current policy

Max. file size: 256 MB.

What coverage are you looking for?

Primary

Excess

Select the sum insured are you looking for:

The insurer may or may not be willing to accommodate your request.

Provide sum insured required

The insurer may or may not be willing to accommodate your request

Select the sum insured are you looking for:

The insurer may or may not be willing to accommodate your request.

Provide sum insured required

The insurer may or may not be willing to accommodate your request

Select the self-insured retention are you looking for:

The insurer may or may not be willing to accommodate your request.

Provide the self-insured retention required

The insurer may or may not be willing to accommodate your request

What attachment point are you looking for from us?

Please enter a number not less than $250,000.

What is the self-insured retention under your primary policy?

Is the proposed primary and/or underlying policy(ies) 'claims made' or 'occurrence'?

Is the proposed primary and/or underlying policy(ies) 'per victim' or 'per perpetrator'?

Detail the proposed primary insurer and, if applicable, all other underlying insurers:

What retroactive date are you looking for?

If the retroactive date you request is more than 5 years, we will need to show the insurer you have maintained coverage continuously from the date requested. Please ensure you up-load documentary evidence of this when you submit this form. The insurer may or may not accommodate your request.

Describe how you handle allegations or suspicions of any form of sexual abuse or misconduct:

Has applicant had any claim for any form of sexual abuse or misconduct made against it in the last 10 years?

Yes

Please furnish the past 10 years first dollar loss history for all sexual abuse and misconduct claims, regardless of when the abuse occurred

Year

# of circumstances

# of claims

Total loss paid

Total expense paid

Total current loss reserves

Total current expense reserves

Total incurred (paid + reserves)

A circumstance involves knowledge of any information that would lead a reasonable person to suspect that a claim of a type potentially covered by sexual abuse or misconduct insurance could be made in the future, even though full information is not then available. A claim involves receipt of a suit demanding damages or other relief.

If you have this information available in a spreadsheet, please up-load it here.

Accepted file types: pdf, xls, doc, Max. file size: 256 MB.

Please provide a complete description of each individual claim and how it was resolved.

We will require the following information: The alleged victim/claimant; The alleged perpetrator/defendant; Their ages; The venue; When the abuse is alleged to have occurred; When the claim was made; The nature of the claim and allegations; The name of your defense attorney and law firm; The name of the plaintiff attorney and law firm; If closed, how much was paid in defense and settlement; If open, claimant's demand, insurer reserve, defense costs incurred to-date, your settlement offer, and your estimate of the settlement amount; Details of remedial actions taken to prevent a recurrence. Please use the upload button below if this helps provide more detail.

Has any individual working for or with the applicant, now or in the past, ever been accused or suspected of any form of inappropriate sexual behaviour of any kind?

Yes

Please provide a complete description of the accusation or suspicion and how the situation was resolved.

Have anyone who works for or with the applicant ever been the subject of a claim or suit alleging or involving any type of inappropriate sexual behaviour?

Yes

Please provide a complete description of the claim or suit and how the situation was resolved.

Are you aware of any situation or circumstance that could lead to a claim for any type of inappropriate sexual behaviour being made against the applicant or any individual working for or with the applicant?

Yes

Please provide full details of any situation or circumstance that could lead to a claim for any type of inappropriate sexual behaviour being made against the applicant or any individual working for or with the applicant.

If you need to up-load documents to us, so we understand any of your answers better, please upload them here.

Drop files here or

Accepted file types: pdf, , Max. file size: 256 MB.

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Jeama SAM Insurance Application

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