Name: BCG Advisors
Price range: $$

"*" indicates required fields

1General Organization Information

2Mailing Address & Physical Location(s)

3Primary Contact Information

4Operations & Services Offered

5Medical & Clinical Operations

6Staffing & Personnel

7Volunteers

8Abuse & Molestation Risk Management

9Property & Equipment

10Vehicles & Mobile Medical Units

11Governance & Board

12Cyber & Data Security

13Financial & Prior Insurance Information

14Additional Information

This field is for validation purposes and should be left unchanged.

General Organization Information

Basic information about your organization.

Legal Name of Organization*

DBA / Operating Name (if different)

EIN (Employer Identification Number)*

Date Organization Was Established

Nonprofit Status*

501(c)(3) Nonprofit

Other Nonprofit Designation

Not Currently a Nonprofit

Main Phone Number*

Website URL

Include https://

Mailing Address & Physical Location(s)

Mailing Address*

Street Address Address Line 2 City State ZIP Code

Total Number of Locations*

Physical Location Address(es)*

If different from the mailing address, or if there are multiple locations, please list each address (one per line).

Primary Contact Information

Basic information about the primary contact for this operation.

Primary Contact Name*

First Name Last Name

Primary Contact Title

Primary Contact Email*

Primary Contact Phone*

Operations & Services Offered

Annual Operating Budget / Total Revenue*

Approximate total annual revenue or operating budget (e.g., $450,000).

Description of Mission and Primary Services*

Which services are offered at your location(s)?*

(Select all that apply)

Pregnancy Testing

Ultrasound

STI/STD Testing and Treatment

Options Counseling

Parenting Classes

Material Assistance (diapers, formula, etc.)

Post-Abortion Recovery Support

Adoption Referrals

Fatherhood Programs

Abortion Pill Reversal (APR) Consultation/Treatment

Mobile Medical Unit Services

Other

Does your organization offer Abortion Pill Reversal (APR) consultation or treatment?*

Yes

Please describe your APR protocol

Briefly describe how APR consultations and treatment are conducted at your organization.

Who administers APR treatment?

e.g., physician, nurse practitioner, registered nurse

Are any medical procedures performed beyond ultrasound (e.g., lab draws, injections)?*

Yes

Please describe these procedures

Hours of Operation*

List operating hours for each location/day.

Are services offered evenings or weekends?*

Yes

Does the organization operate a 24/7 helpline?*

Yes

Estimated Number of Clients Served Annually*

Medical & Clinical Operations

Is the clinic licensed as a medical facility in its state?*

Yes

License Number and Issuing State

Number of Ultrasound Machines*

Ultrasound Machine Details

For each machine, list the make, model, and approximate value.

Who performs ultrasounds?

(Select all that apply)

Registered Nurse (RN)

Sonographer / RDMS-Certified

Physician

Other

Medical Director Name*

Medical Director Credentials

e.g., MD, DO, NP, RN

Medical Director Licensing State

Are all clinical staff and volunteers performing medical tasks properly licensed/certified for their role?*

Yes

Does the organization have written clinical protocols and a quality assurance/medical oversight process?*

Yes

Are client records maintained in accordance with HIPAA or similar privacy standards?*

Yes

Staffing & Personnel

Total Paid Employees (Full-Time)*

Total Paid Employees (Part-Time)

Total Annual Payroll

Approximate total annual payroll for all employees (e.g., $180,000).

Job Descriptions / Duties for Staff Categories

Briefly describe the duties for each staff category, especially anyone in a clinical or counseling role.

Are background checks conducted on employees?*

Yes - at hiring only

Yes - periodically

Does the organization have an employee handbook with HR policies (harassment, termination, etc.)?*

Yes

Do any employees interact one-on-one with minors?*

Yes

Volunteers

Total Number of Active Volunteers*

What roles do volunteers fill?

(Select all that apply)

Intake

Peer Counseling

Administrative

Driving / Transportation

Childcare

Other

N/A

Are volunteers background-checked?*

Yes - at onboarding

Yes - periodically

N/A

Is there a documented volunteer training/orientation program?*

Yes

N/A

Are volunteers ever alone with clients, including minors?*

Yes

N/A

Abuse & Molestation Risk Management

Does the organization have a written child/vulnerable-person protection policy?*

Yes

Are background checks required for anyone with access to minors (staff and volunteers)?*

Yes

Is there a two-adult rule or similar supervision policy for one-on-one interactions?*

Yes

Has the organization had any past allegations, investigations, or claims related to abuse (regardless of outcome)?*

Yes

Please provide details, including approximate dates and current status

Is there a designated reporting procedure for suspected abuse?*

Yes

Property & Equipment

Are your location(s) owned or leased?*

Owned

Leased

Both (some owned, some leased)

Lease Terms and Any Landlord Insurance Requirements

Square Footage of Each Location*

Construction Type and Year Built for Each Location*

Replacement Value of Owned Building(s)

Replacement Value of Contents / Equipment*

What security systems are in place?

(Select all that apply)

Alarm System

Security Cameras

Monitored Security Service

None

Has the organization had any prior property losses (fire, water damage, theft) in the last 5 years?*

Yes

Please describe the loss(es), including approximate dates

Vehicles & Mobile Medical Units

Does the organization own, lease, or operate any vehicles?*

Yes

How would you like to provide your list of vehicles

Enter vehicles manually

Upload schedule of vehicles

List of Vehicles

VIN

Year

Make

Model

Upload schedule of vehicles

Max. file size: 20 MB.

List Drivers and Their Roles

Include each driver's name and role/relationship to the organization.

Are motor vehicle records (MVRs) checked for drivers?

Yes

Are vehicles used to transport clients?

Yes

Does the organization operate a mobile medical unit (e.g., mobile ultrasound vehicle)?*

Yes

Describe the Services Performed Onboard the Mobile Unit

Is the mobile unit self-propelled or a trailer?

Self-Propelled

Trailer

Governance & Board

Number of Board Members*

How often does the board meet?*

Are board members compensated?*

Yes

Does the board carry out oversight of finances, HR policies, and risk management?*

Yes

Has the organization had any past D&O claims or lawsuits against board members or officers?*

Yes

Please provide details, including approximate dates and current status

Does the organization have written bylaws and a conflict-of-interest policy?*

Yes

Cyber & Data Security

What systems store client medical/personal information?*

(Select all that apply)

Electronic Health Record (EHR) System

Paper Records

CRM / Database

Cloud Storage

Other

Is data encrypted at rest and in transit?*

Are staff and volunteers trained on data privacy and phishing awareness?*

Yes

Has the organization experienced any data breach, ransomware event, or unauthorized access in the past 5 years?*

Yes

Please describe, including approximate date and how it was resolved

Who Has Administrative Access to Client Databases?*

List roles/titles (not necessarily names) with administrative access.

Financial & Prior Insurance Information

Does the operation currently have any insurance policies?*

Yes

List Current Insurance Carrier(s)

Policy Type

Carrier Name

Expiration Date (mm/dd/yyyy)

Policy Limit

Has any coverage been declined, cancelled, or non-renewed in the past?*

Yes

Please describe

Does the organization have any current or prior claims/lawsuits (any line of coverage) in the last 5 years?*

Yes

Please provide the date, description, and status for each claim

Does the organization host fundraising events involving the public (galas, walks, etc.)?*

Yes

Please describe the event(s)

Additional Information

This information will be used to begin a no-cost, no-pressure coverage review tailored to your organization.

Is there anything else about your organization's operations that your insurance advisor should know?

Additional Documents (Optional)

e.g. Current insurance policies, schedule of drivers or vehicles, certificates of insurance, landlord contracts, licenses, etc.

Drop files here or

Max. file size: 20 MB.

All the above information is accurate and true to the best of my knowledge.*

Yes

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Insurance Application for Medical, Dental, & Private Practice Clinics

General Organization Information

Mailing Address & Physical Location(s)

Primary Contact Information

Operations & Services Offered

Medical & Clinical Operations

Staffing & Personnel

Volunteers

Abuse & Molestation Risk Management

Property & Equipment

Vehicles & Mobile Medical Units

Governance & Board

Cyber & Data Security

Financial & Prior Insurance Information

Additional Information

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Insurance Application for Medical, Dental, & Private Practice Clinics

General Organization Information

Mailing Address & Physical Location(s)

Primary Contact Information

Operations & Services Offered

Medical & Clinical Operations

Staffing & Personnel

Volunteers

Abuse & Molestation Risk Management

Property & Equipment

Vehicles & Mobile Medical Units

Governance & Board

Cyber & Data Security

Financial & Prior Insurance Information

Additional Information

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Don’t have an account?

Are you paying too much for your business insurance or employee benefits program?

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