Exhibit_K-_1._Law_Enforcement_Liability_Application_Juvenile_Detention_(002).pdf

Law Enforcement Liability application continued

42. Which of the following best describes your facility?

Temporary holding facility (under 8 hours – no overnight)

Temporary holding cell (from 8 to 24 hours)

Jail - for persons serving time, awaiting trial or transfer.

Prison – maximum security

43. When was your facility built?

44. When was your facility last renovated?

45. What is the state certified capacity?

46. What is the average daily inmate population?

47. Does your facility house:

Adult prisoners only? Yes No

Males and females? Yes No

Violent and non-violent prisoners? Yes No

48. How many attempted suicides have there been in your facility in the last five years?

49. Has anyone ever successfully committed Yes No suicide in your facility?

If yes, please attach explanation.

50. Do you maintain consistent separation between:

Adults and juveniles? Yes No

Males and females? Yes No

Violent and non-violent inmates? Yes No

51. Is your facility equipped with surveillance systems to monitor activity in the following areas? If so, please check.

Individual detention cells? Audio Video

Secured common areas? Audio Video

Booking area? Audio Video

Sally port? Audio Video

52. When was your facility last inspected by the following:

State Corrections Officials? date:

Fire Inspectors? date:

Department of Health? date:

53. Do you have standard fire protection Yes No systems including smoke detectors and fire alarms?

54. Do dispatchers serve as jailers? Yes No

If so, do they receive the same training? Yes No

V. DETENTION FACILITY

If you do NOT have a detention facility of any kind, please check this box and skip to the next section. No Detention Facility

55. Are there Hold Harmless Agreements used in Yes No all of the Entity’s contracts?

56. Do you have formal written policies and procedures for:

Intake screening and classification? Yes No

Medical screening? Yes No

Suicide detection and prevention? Yes No

Periodic walk-through of the facility? Yes No

Administration and control of medication? Yes No

Use of force? Yes No

Emergency evacuation? Yes No

Communicable diseases? Yes No

PREA Act Yes No

57. When was your manual last updated?

a. Is your manual reviewed by legal counsel? Yes No

58. Has your facility ever been subject to a court Yes No order or Consent Decree?

If yes, please explain:

59. Occupant’s Status:

Convicted Felon Convicted Misdemeanor

INS Detainees US Marshall Detainees

Pre-Trial Detainees

Other/Contracted (please describe):

60. Is medical clearance required before Yes No detention when drug/alcohol is involved?

61. Is monitoring done by jail personnel or Yes No medical personnel on arrests involving drug/alcohol use?

62. How does detention facility ensure cell checks are performed?

63. Do you provide inmate transport? Yes No

If yes, please describe:

Page 4 of 6 Ambridge GroupAmbridge Group LEL App (0615)

EXHIBIT K

64. Please check the classification that best describes the health care services you provide:

Clinic, Dispensary or Infirmary

Mental or Psychopathic Treatment Center

Medical or Surgical Facility

Drug or Substance Abuse Treatment Center

None

Other (describe):

65. Describe the nature and type of health care you provide:

66. Number of Health Care Beds:

Square Footage of Health Care Facility:

67. Do you employ or contract with any of the following:

Doctor(s)? Employ Contract How many?

Nurse(s)? Employ Contract How many?

Dentist? Employ Contract How many?

Psychologist? Employ Contract How many?

68. Advise whether each of the following maintain their own coverage and if yes, comment the policy limits:

Professional E&O liability?

Medical malpractice?

Policy Limits:

Doctor Yes No Yes No

Nurse Yes No Yes No

Dentist Yes No Yes No

Psychologist Yes No Yes No

Law Enforcement Liability application continued

V. DETENTION FACILITY continued

69. Exposure Information:

Facility Number of Facilities

Total Square Footage

Number of Cells

Design Capacity

Average Inmate

Population

Maximum Capacity in Past

12 Months

Date Built

Jail

Holding Cell

Juvenile Detention Center

Prison

Other:

Attachment: Please provide 1.) a copy of your current Detention Facility Policies and Procedure Manual governing those areas specified above, and 2.) a copy of your latest state inspection report, if applicable.

Page 5 of 6 Ambridge GroupAmbridge Group LEL App (0615)

Law Enforcement Liability application

VI. ATTESTATION

The undersigned being authorized by, and acting on behalf of, the applicant and all persons or concerns seeking insurance, has read and understands this Application, and declares that all statements set forth herein are true, complete and accurate.

The undersigned further declares and represents that any occurrence or event taking place prior to the inception of the policy applied for, which may render inaccurate, untrue or incomplete any statement made herein will immediately be reported in writing to the insurer. The undersigned acknowledges and agrees that the applicant’s submission and Insurer’s receipt of such written report, prior to the inception of the policy applied for, is a condition precedent to coverage.

The signing of this Application does not bind the undersigned to purchase the insurance, nor does review of the Application bind the insurance company to issue a policy. The applicant does hereby agree that this policy, if issued, is issued in reliance upon the truth of this application, including all requested attachments, which will be incorporated into and made a part of this policy.

WARNING: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE

COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF

CLAIM CONTANING MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THEPURPOSE

OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A

FRAUDULENT INSURANCE ACT, WHICH IS A CRIME.

Applicant’s Authorized Signature

Title

Date

Page 6 of 6 Ambridge GroupAmbridge Group LEL App (0615)

Video review is used to randomly check and ensure cell checks are being performed