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<br />Insured Name: CALDWELL FIRE DEPARTMENT, INC <br />Tuesday, March 11, 2025 Page 2 <br />Insured’s Name: <br />Insured’s Mailing Address: <br />Notice: As changes are made throughout this document, a system-generated ""pdate indicator <br />will appear in the left margin. <br />Contact Name/Title:# Full-Time Employees:1 <br /># Part-Time Employees:2 <br />Contact Phone:# Active Volunteers:3 <br />Contact Mobile: <br />Contact Email: <br /># Publicly Elected Trustees/ <br />Commissioners/Directors: <br />Web Site: <br />Federal I.D. #: <br />1 A full-time employee is one who is regularly scheduled to work 35 or more hours a week. These hours may be in a set rotation or in varying shifts from <br />week to week. <br />2 A part-time employee is one who on average works less than 35 hours a week, or has no set number of hours a week, or receives an hourly rate per call. <br />3 A volunteer performs services without expectation of any compensation. <br />Type of Organization:Fire Department Relief Association <br />Fire Department w/Ambulance County/State Association <br />Ambulance Corps Search & Rescue Team <br />Rescue Squad (no ambulances)*911 Emergency Dispatch <br />First Responder Training School <br />Hospital EMS Haz Mat Team <br />Other (describe): <br />* If the insured has ambulances they should be classified as an Ambulance Corps even though their entity name may include "Rescue Squad". <br />Population of area served on a first call basis: <br />Number of Responses per Year: <br />Fire and other non-medical runs. <br />Emergency medical or first responder medical runs. <br />Include number of runs involving medical treatment at the scene of an emergency or while in transport (or both). <br />Non-emergency transports. <br />Are all volunteers covered by Workers' Compensation? Yes No N/A <br />Are all paid employees covered by Workers' Compensation? Yes No N/A <br />If no to either of the above, is there an Accident & Sickness policy in <br />force with primary medical benefits of at least $10,000? Yes No <br />BRAD ALLISON - CHIEF 0 <br />2 <br />U 919.451.9074 35 <br />U <br />56-1194798 <br />U 5,000 <br />U <br />160 <br />241 <br />0 <br />Docusign Envelope ID: 98CFD7CD-5E86-4B80-B3CD-3F09E1F5D0CF