Fillable ADOPTION / FOSTER CARE APPLICATION (Philadelphia Insurance Companies)

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ADOPTION / FOSTER CARE APPLICATION (Philadelphia Insurance Companies)

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ADOPTION / FOSTER CARE APPLICATION
Applicant Name:
Mailing Address:
Total Staff (including office, janitorial, maintenance, etc.):
Full Time:
Part Time:
SIC #:
FEIN #:
Website Address:
For-Profit
Annual Revenue: $
Is the Applicant’s organization more than 25% owned by a private equity fund structure?
Yes
No
If yes, provide name of private equity firm:
Number of years this facility has been: In Operation:
Under current management:
Risk Management Contact:
Number:
Email:
SECTION I
ADOPTION PLACEMENT AGENCY
N/A
FOSTER CARE PLACEMENT AGENCY
N/A
1.
Is the Applicant licensed in all states in which it operates?
Yes
No
List states:
2.
Are the adoption services:
Opened
Closed
Total number of anticipated adoptions in the next 12 months:
Is the adoption agency Hague approved?
Yes
No
Does Applicant do Embryo Adoptions?
Yes
No
3.
International adoptions:
Yes
No
Total number of anticipated international adoptions in the next 12 months:
4.
Total number of foster families at any one time:
5.
Anticipated number of foster children over the next 12 months:
Ages: Less than 1 year: 1-5: 6-10: Over 10:
Please identify the number of special needs foster care placement included in this number:
6.
Average number of foster children who are placed multiple times:
7.
Total number of training hours for each foster family prior to placement of first child:
8.
Total annual number of training hours for each family:
9.
Are caseworkers supervised?
Yes
No
Are decisions made by a team?
Yes
No
10.
Are home studies conducted?
Yes
No
What are staff member’s credentials?
11.
Is there a written procedure in place to analyze potential applicants?
Yes
No
12.
Are criminal records checked prior to approval of a home?
Yes
No
13.
Does the Applicant verify homeowners insurance or renters insurance?
Yes
No
14.
Does the Applicant have written procedures for dealing with a report of abuse?
Yes
No
15.
Are children given thorough medical examinations, with prior conditions noted, before they are
placed?
Yes
No
16.
Is counseling provided to the birthparents after placement?
Yes
No
17.
Are children given to adoptive parents upon release from hospital?
Yes
No
18.
Are they placed in a foster home until the time lapses for the mother to change her mind?
Yes
No
19.
Do the adoptive/foster parents receive special counseling after placement?
Yes
No
20.
Does the Applicant do follow-up visits after placement has been made?
Yes
No
Are these visits unannounced?
Yes
No
How often do they occur?
When do these visits stop?
21.
What are the rights of the child’s biological grandparents?
22.
Total stipend amount paid to foster parents annually:
Foster Care annual stipend: $
23.
Total annual receipts for:
Domestic Adoptions: $
International Adoption: $
Adoption and Foster Care
Page 1 of 3
© 2019 Philadelphia Consolidated Holding Corp.
03/2019
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24.
Please advise additional screening criteria of Foster Parents to satisfy eligibility for special needs
placements, and indicate if follow up visits are more frequent if the placement involves a special needs
child.
25.
Are any of the Applicant’s Foster Care Services contracted to third party organizations, or, does the
Applicant conduct any foster care operations as a contractor on behalf of a separate organization?
Yes
No
If yes, please complete Section II, Question 8 in its entirety for your Foster Care Services.
SECTION II – FOSTER CARE SERVICES PROVIDER
1.
Number of active Foster Homes / Foster Families in service:
2.
Total number of Foster Children served annually:
3.
Number of years the Applicant has operated Foster Care program:
4.
Foster Care Services (check all that apply)
Foster Home/Foster Family Screening (Studies)
Foster Care Assessments
Foster Parent counseling
Foster Home/Foster Family Certification
Case Management
Emergency Shelter
Foster Home/Foster Family Licensing
In Home support services
5.
Please list any affiliated Foster Child Placement Agencies:
a.
Do Agencies listed above carry primary liability insurance?
Yes
No
b.
Do Agencies listed above offer claim settlements under a state fund?
Yes
No
6.
Does the Applicant follow state regulations mandating Foster Care Procedures?
Yes
No
7.
Are audit procedures in place to ensure home visits are being conducted?
Yes
No
Are there standards of practice with respect to documentation and is there a method for immediate
reporting / escalation for emergency incidents?
Yes
No
8.
Are any of the Applicant’s Foster Care Services contracted to a third party organization, or, does the
Applicant conduct any foster care operations as a contractor on behalf of a separate organization?
Yes
No
If yes, please answer the below:
a.
Does the Applicant confirm that General Liability coverage, Professional Liability coverage and
Sexual Abuse or Molestation Liability coverage are carried at equal limits by all contracting
parties?
Yes
No
b.
Does the Applicant require independent contractors to add them as additional insured onto their
policy?
Yes
No
c.
Is the Applicant required by written contract to hold harmless, indemnity or add any third party
organization as additional insured?
Yes
No
d.
Do all of the Applicant’s contracting or subcontracting agreements include hold harmless &
indemnification clauses in their favor or, at a minimum, mutually exclusive?
Yes
No
e.
Does the applicant execute a hold harmless agreement with the individual foster families that
they serve?
Yes
No
f.
Please list any third party entities with whom the Applicant has contracted for foster care services
and identify what amount of the Applicant’s services are provided on a contractual basis:
Contracted Organization
Service
% of Operations
%
%
%
%
%
%
Total
%
Note: Contracts include those in which the Applicant is either the contractor or subcontractor.
% of operations represents foster care operations, totals should equal 100%.
All contract agreements and provisions are subject to receipt and review.
Adoption and Foster Care
Page 2 of 3
© 2019 Philadelphia Consolidated Holding Corp.
03/2019
Clear Application
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FRAUD STATEMENT AND SIGNATURE SECTIONS
The Undersigned states that he/she is an authorized representative of the Applicant and declares to the best of his/her knowledge and belief
and after reasonable inquiry, that the statements set forth in this Application (and any attachments submitted with this Application) are true
and complete and may be relied upon by Company * in quoting and issuing the policy. If any of the information in this Application changes
prior to the effective date of the policy, the Applicant will notify the Company of such changes and the Company may modify or withdraw the
quote or binder.
The signing of this Application does not bind the Company to offer, or the Applicant to purchase the policy.
*Company refers collectively to Philadelphia Indemnity Insurance Company and Tokio Marine Specialty Insurance Company
VIRGINIA APPLICANT: READ YOUR POLICY. THE POLICY OF INSURANCE FOR WHICH THIS APPLICATION IS BEING MADE, IF ISSUED,
MAY BE CANCELLED WITHOUT CAUSE AT THE OPTION OF THE INSURER AT ANY TIME IN THE FIRST 60 DAYS DURING WHICH IT IS IN
EFFECT AND AT ANY TIME THEREAFTER FOR REASONS STATED IN THE POLICY.
FRAUD NOTICE STATEMENTS
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR
INSURANCE CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS, FOR THE PURPOSE OF MISLEADING, INFORMATION
CONCERNING ANY FACT MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND SUBJECTS THAT PERSON TO
CRIMINAL AND CIVIL PENALTIES (IN OREGON, THE AFOREMENTIONED ACTIONS MAY CONSTITUTE A FRAUDULENT INSURANCE ACT WHICH MAY
BE A CRIME AND MAY SUBJECT THE PERSON TO PENALTIES). (IN NEW YORK, THE CIVIL PENALTY IS NOT TO EXCEED FIVE THOUSAND DOLLARS
($5,000) AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION). (NOT APPLICABLE IN AL, AR, AZ, CO, DC, FL, KS, LA, ME, MD, MN,
NM, OK, PA, RI, TN, VA, VT, WA AND WV).
APPLICABLE IN AL, AR, AZ, DC, LA, MD, NM, RI AND WV: ANY PERSON WHO KNOWINGLY (OR WILLFULLY IN MD) PRESENTS A FALSE OR
FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR WHO KNOWINGLY (OR WILLFULLY IN MD) PRESENTS FALSE INFORMATION IN AN
APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES OR CONFINEMENT IN PRISON.
APPLICABLE IN COLORADO: IT IS UNLAWFUL TO KNOWINGLY PROVIDE FALSE, INCOMPLETE, OR MISLEADING FACTS OR INFORMATION TO AN
INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE COMPANY. PENALTIES MAY INCLUDE
IMPRISONMENT, FINES, DENIAL OF INSURANCE AND CIVIL DAMAGES. ANY INSURANCE COMPANY OR AGENT OF AN INSURANCE COMPANY WHO
KNOWINGLY PROVIDES FALSE, INCOMPLETE, OR MISLEADING FACTS OR INFORMATION TO A POLICYHOLDER OR CLAIMANT FOR THE PURPOSE
OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE POLICYHOLDER OR CLAIMANT WITH REGARD TO A SETTLEMENT OR AWARD PAYABLE FROM
INSURANCE PROCEEDS SHALL BE REPORTED TO THE COLORADO DIVISION OF INSURANCE WITHIN THE DEPARTMENT OF REGULATORY
AGENCIES.
APPLICABLE IN FLORIDA AND OKLAHOMA: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY INSURER
FILES A STATEMENT OF CLAIM OR AN APPLICATION CONTAINING ANY FALSE, INCOMPLETE, OR MISLEADING INFORMATION IS GUILTY OF A
FELONY (IN FL, A PERSON IS GUILTY OF A FELONY OF THE THIRD DEGREE).
APPLICABLE IN KANSAS: AN ACT COMMITTED BY ANY PERSON WHO, KNOWINGLY AND WITH INTENT TO DEFRAUD, PRESENTS, CAUSES TO BE
PRESENTED OR PREPARES WITH KNOWLEDGE OR BELIEF THAT IT WILL BE PRESENTED TO OR BY AN INSURER, PURPORTED INSURER, BROKER
OR ANY AGENT THEREOF, ANY WRITTEN, ELECTRONIC, ELECTRONIC IMPULSE, FACSIMILE, MAGNETIC, ORAL, OR TELEPHONIC COMMUNICATION
OR STATEMENT AS PART OF, OR IN SUPPORT OF, AN APPLICATION FOR THE ISSUANCE OF, OR THE RATING OF AN INSURANCE POLICY FOR
PERSONAL OR COMMERCIAL INSURANCE, OR A CLAIM FOR PAYMENT OR OTHER BENEFIT PURSUANT TO AN INSURANCE POLICY FOR
COMMERCIAL OR PERSONAL INSURANCE WHICH SUCH PERSON KNOWS TO CONTAIN MATERIALLY FALSE INFORMATION CONCERNING ANY FACT
MATERIAL THERETO; OR CONCEALS, FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO.
APPLICABLE IN KENTUCKY: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSONS
FILES AN APPLICATION FOR INSURANCE CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS, FOR THE PURPOSE OF
MISLEADING, INFORMATION CONCERNING ANY MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME.
APPLICABLE IN MAINE, TENNESSEE, VIRGINIA AND WASHINGTON: IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE OR MISLEADING
INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE COMPANY. PENALTIES MAY INCLUDE IMPRISONMENT,
FINES OR A DENIAL OF INSURANCE BENEFITS.
APPLICABLE IN PENNSYLVANIA: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON
FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS FOR THE
PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A
CRIME AND SUBJECTS SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES.
APPLICABLE IN NEW YORK: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON
FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE
PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A
CRIME AND SHALL BE SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE STATE VALUE OF THE CLAIM FOR EACH
SUCH VIOLATION.
NAME (PLEASE PRINT/TYPE) TITLE
(MUST BE SIGNED BY THE PRESIDENT, CHAIRMAN, CEO OR EXECUTIVE
DIRECTOR)
_____
________________________________________________________
SIGNATURE DATE
SE
CTION TO BE COMPLETED BY THE PRODUCER/BROKER/AGENT
PRODUCER AGENCY
(If this is a Florida Risk, Producer means Florida Licensed Agent)
PRODUCER LICENSE NUMBER
(If this a Florida Risk, Producer means Florida Licensed Agent)
ADDRESS (STREET, CITY, STATE, ZIP)
Adoption and Foster Care
Page 3 of 3
© 2019 Philadelphia Consolidated Holding Corp.
03/2019
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ADOPTION FOSTER CARE APPLICATION (Philadelphia Insurance Companies)

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Completed 29 July 2020

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