Fillable AH HOME HEALTH And MEDICAL STAFFING 1 (Kinsale Insurance)

Fill Online, Printable, Fillable, Blank AH HOME HEALTH And MEDICAL STAFFING 1 (Kinsale Insurance) Form

Use Fill to complete blank online KINSALE INSURANCE pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

AH HOME HEALTH And MEDICAL STAFFING 1 (Kinsale Insurance)

On average this form takes 97 minutes to complete

The AH HOME HEALTH And MEDICAL STAFFING 1 (Kinsale Insurance) form is 17 pages long and contains:

  • 2 signatures
  • 184 check-boxes
  • 294 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your Kinsale Insurance forms online.

BROWSE KINSALE INSURANCE FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Page 1 of 11
Requesting Professional Liability:
Requested Retro Date: _________
Professional Liability Limits
Professional Liability Deductible
$100,000 / $300,000
$200,000 / $600,000
$250,000 / $750,000
$500,000 / $1,500,000
$1,000,000 / $1,000,000
$1,000,000 / $2,000,000
$1,000,000 / $3,000,000
Other: _______________
$2,500
$5,000
$7,500
$10,000
$15,000
$20,000
$25,000
Other: _______________
Requesting General Liability:
Requested Retro Date: _________ or Occurrence Based Coverage
General Liability Limits
General Liability Deductible
$100,000 / $300,000
$200,000 / $600,000
$250,000 / $750,000
$500,000 / $1,500,000
$1,000,000 / $1,000,000
$1,000,000 / $2,000,000
$1,000,000 / $3,000,000
Other: _______________
$2,500
$5,000
$7,500
$10,000
$15,000
$20,000
$25,000
Other: _______________
Requesting Employee Benefits Liability (supplement required):
Requested Retro Date: _________
Employee Benefits Liability Limits
Employee Benefits Liability Deductible
$100,000 / $300,000
$200,000 / $600,000
$250,000 / $750,000
$500,000 / $1,500,000
$1,000,000 / $1,000,000
$1,000,000 / $2,000,000
$1,000,000 / $3,000,000
Other: _______________
$1,000
$2,500
$5,000
$7,500
$10,000
$15,000
$20,000
$25,000
Requesting Non-Owned Auto Liability:
Non-Owned Auto Liability Limits
$100,000
$200,000
$250,000
$500,000
$1,000,000
Other: _______________
*Requested coverage may or may not be offered please review any quote issued for actual terms
and conditions available. Completion of this application neither binds coverage nor guarantees
that policy will be issued.
REQUESTED COVERAGE – HOME HEALTH AND MEDICAL STAFFING
Page 2 of 11
ALLIED HEALTH – HOME HEALTH AND STAFFING APPLICATION
Instructions to the Applicant – please complete this application in ink and answer all questions completely. Attach extra
sheets as necessary should you run out of space provided. An incomplete or illegible application cannot be processed.
Completion of this application neither binds coverage nor guarantees that a policy will be issued.
• Provide a fully completed application, signed and dated by the owner, partner, or officer not earlier than 45 days
before the proposed effective date of coverage.
• If a question is not applicable, then state “N/A”.
• The following information must be submitted with the completed application:
- Copy of your current professional liability insurance Declarations Page (claims made policies must
reflect the retroactive date)
- Copy of all advertising that you use
- 5-year company loss runs, valued within the last 60 days
8. Date Established: _____________________ Years under current management: _____________
9. Applicant is a:
Individual
Professional Associations
Corporation
Partnership
LLC
Joint Venture
Other:____________________________________
1. Full Name of Applicant (Including DBA’s): _______________________________________________________________
2. Mailing Address:_____________________________________________________________________________________
STREET CITY COUNTY STATE ZIP
3. Location Address(es): Check here if same as mailing:
(1) ________________________________________________________________________________________
STREET CITY COUNTY STATE ZIP
(2) ________________________________________________________________________________________
STREET CITY COUNTY STATE ZIP
(3) ________________________________________________________________________________________
STREET CITY COUNTY STATE ZIP
(4) ________________________________________________________________________________________
STREET CITY COUNTY STATE ZIP
Attach Additional Pages as Needed
4. Website Address:
www. _______________________________
5. Telephone:
______________________
6. Inspection/Risk Management Contact Name:
7. Inspection/Risk Management Contact E-mail:
GENERAL INFORMATION
Kinsale Insurance Company
P. O. Box 17008
Richmond, VA 23226
(804) 289-1300
www.kinsaleins.com
Page 3 of 11
10. Enterprise is: For Profit Not For Profit
11. Is this entity owned by, associated with or controlled by any other entity? Yes No
If yes, please provide details:
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
12. Type of Operations (check all that apply)
Home Health Care
Medical Staffing/Nurse Registry
Medical Equipment Supplier
Other
(specify)
________________________________________
13. Are you accredited by the Joint Commission, Community Health Accreditation Program
(CHAP) or any other accrediting organization? If “yes” please specify:
__________________________________________________________________
__________________________________________________________________
Yes No
14. Please state sources and amounts of total revenue:
Source Last 12 months Next 12 months
Charitable contributions $________________ $_________________
Government Funding $________________ $_________________
Fee for services $________________ $_________________
Other $________________ $_________________
Total Gross Revenue $________________ $_________________
15. Please indicate percentage of time spent in the following work locations:
Private Home
______%
Hospital Staffing
Assisted Living
______%
Operating Room
______%
Nursing Home
______%
Emergency Room
______%
Institutional Hospice
______%
Labor & Delivery
______%
Ambulatory Surgery Center
______%
Neonatal (NICU)
______%
Adult Day Care
______%
Adult Intensive Care Unit
______%
Clinic
______%
Pediatric Intensive Care Unit
______%
Physician’s Office
______%
Jail, Prison or other
Correctional Facility
______%
Other
(specify where)
______________________
______%
Other Hospital
(specify where)
______________________
______%
OPERATIONS
Page 4 of 11
16. Percentage of Types of Services Provided (total must equal 100%)\
Personal Care Chore or Companion
______%
Respiratory Therapy
______%
Rehabilitation – including Physical,
Occupational, or Speech Therapy
______%
Radiation Therapy
______%
Infusion Therapy
______%
Skilled Nursing Care
______%
Hospice – In Home
______%
Pediatric Care
______%
Supplemental Staffing
______%
Skin Care or Bedsore Wound Care
______%
Obstetrical Services
______%
Medical Equipment Supplier
______%
Chemotherapy
______%
In Home Dialysis
______%
Cardiac Care
______%
17. Does the applicant provide any overnight bed facilities?
Yes No
18. Does the applicant perform any treatment or services on the applicant’s premises?
Yes No
19. Does the applicant care or treatment to ventilator or tracheotomy patients?
If yes – please advise the percent of services ______%
Yes No
20. Does the applicant perform any permanent placements of staff?
If “yes” – please indicate:
percent of permanent placements ______% and temporary placements ______%
Yes No
21.
Type of Health Care Provider
# of
Employees
Annual
Employee
Hours Worked
# of
Independent
Contractors
Annual
Contractors
Hours Worked
Personal Companion/ Homemaker
Live In Companions
Certified Nurse Aid (CNA)
Licensed Practical Nurse (LPN)
Registered Nurse (RN)
Medical Technician
Nurse Practitioner
Speech Therapist
Occupational Therapist
Physical Therapist
Social Worker
Physician Assistant
CRNA
Nurse Midwife
Physicians (all types)
Other:
Other
STAFF
Page 5 of 11
23. Do ALL employees carry their own professional liability insurance?
a. If “yes” what are the minimum limits of liability they carry?
___________________Per Occurrence
___________________Aggregate
Yes No
24. Do ALL independent contractors carry their own professional liability insurance?
a. If “yes” what are the minimum limits of liability they carry?
___________________Per Occurrence
___________________Aggregate
b. If “no” are you requesting direct coverage for your independently
contracted staff?
Yes No
Yes No
Building Description
Buildings/Wings
#1 #2 #3 #4
Type of Construction: __________ __________ __________ __________
No. of Stories: __________ __________ __________ __________
Square Footage __________ __________ __________ __________
Date Built: __________ __________ __________ __________
Smoke detectors: Yes No Yes No Yes No Yes No
Local/Central station fire alarm: Yes No Yes No Yes No Yes No
Sprinkler System: Yes No Partial Yes No Partial Yes No Partial Yes No Partial
22. Are all above individuals licensed in accordance with applicable state and federal
regulations? (if licensure is required)
Yes No
25. Please provide the name and specialty of the applicant’s Medical Director: _______________________________
Full Time or Part Time - Does the applicant’s Medical Director have direct patient care? YES NO
26. Please indicate all of the hiring/screening procedures used for professionals and paraprofessionals who provide
patient care services on your behalf
:
Check of educational background, or residency program, when applicable.
Check of previous employers ( In writing By Telephone)
Criminal background check ( STATE FEDERAL)
Drug / Alcohol / Abuse Screening (circle all that are used)
Verify any pending license suspensions or revocations, or any pending disciplinary actions by other facilities.
Require information on any professional liability or work-related claim that has previously been made against any
Individual?
27. Does your facility have written job descriptions?
Yes No
28. Do any of the Applicant’s locations have any(explain any “yes” answers on page 8):
a. Exposure to flammables, explosive, chemicals?
b. Catastrophe exposure?
c. Exposure to radioactive materials?
YES NO
YES NO
YES NO
PREMISES INFORMATION – Complete ONLY if you are requesting General Liability Coverage
Page 6 of 11
29. Limits requested:
$100,000
$250,000
$500,000
$1,000,000
Other: (please specify)____________________________
30. Number of OWNED autos? ____________
31. Do you have auto liability for owned autos? Yes No
32. Is Non-Owned auto liability coverage under the owned auto policy? Yes No
33. What type(s) of non-owned autos will be used in your business?
Number of Autos
Private Passenger
Other (specify)
34. How will they be used?_________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
35. What is the maximum distance which a non-owned auto may be driven from your premises? __________miles
36. What percentage of your business involves client transportation? ______%
37. Do your employees or contractors EVER drive a client’s car? Yes No
38. How often are non-owned autos used in your business Daily Weekly Monthly Seldom
39. Please confirm what driver screening procedures are utilized (check ALL that apply):
Obtain and verify valid driver’s license on all employees yearly
Obtain and verify valid personal auto insurance yearly
If indicated, what limits of liability are required? _______________________________
Order and review MVR’s on all employees yearly
Prohibit employees from driving if license is suspended, revoked, or has serious violation such as
DUI, etc.
Explain any exceptions should the applicant NOT use or follow ALL of the above driver screening methods noted above:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
NON-OWNED AUTO - Complete ONLY if you are requesting Non-Owned Auto Coverage
Page 7 of 11
40. TYPE OF EQUIPMENT SOLD OR RENTED (complete table below)
42. Please list professional liability insurance carried for each of the past five years.
Insurer
Dates covered
Limits of Liability
Per claim/ agg.
Deductible
Premium
Retroactive
date
SALES REVENUE RENTAL REVENUE
CATEGORY I.
EXPENDABLE ITEMS – intended for one time usage and disposed (ie
adhesive tape, bandages, hypodermic needles, etc.)
$_________________ $_________________
CATEGORY II.
NON-EXPENDABLE ITEMS – Excluding diagnostic or treatment
equipment or devices. This category includes, but is not limited to,
hospital beds, bathroom safety bars, portable toilets, lifts, or hoists,
walkers, strollers, canes, crutches, wheelchairs, etc.
$_________________ $_________________
CATEGORY III.
DIAGNOSTIC OR TREATMENT DEVICES – This category includes
oxygen and other medical gases used in conjunction with respitory
therapy (excluding ventilators), treatment devices or equipment not
used to sustain life or perform critical life monitoring functions.
Also include are blood pressure gauges, IV pump, portable EKG
machines or sending devices.
$_________________ $_________________
CATEGORY IV.
LIFE SUSTAINING OR CRITICAL LIFE MONITORING EQUIPMENT OR
DEVICES – this category includes dialysis or heart/lung machines,
apnea monitors, SIDS monitors or any other life dependent
monitors or any other equipment or devices that
malfunction/failure or improper function could result in death or
serious deterioration in health condition.
$_________________ $_________________
41. Does the applicant REPAIR or PERFORM MAINTENANCE on any medical supplies and/or
equipment?
a. If “yes” please advise the total Annual Sales: ___________________
b. Types of equipment serviced?
________________________________________________________________
________________________________________________________________
________________________________________________________________
Yes No
COVERAGE HISTORY
MEDICAL EQUIPMENT or SUPPLIES – RENTAL OR SALES - Complete ONLY if you have these operations
Page 8 of 11
43. If the applicant is currently insured under a commercial general liability policy please list coverage for the past five
years.
Insurer
Dates covered
Limits of Liability
Per claim/ agg
Deductible
Premium
Occurrence or
Claims –
Made?
If the current expiring GL policy is claims- made what is the retroactive date? _____________
44. Has the applicant or any of its employees ever had any professional license or license to prescribe and
or dispense narcotics ever been limited, suspended, revoked, denied, or investigated by any licensing
board or regulatory agency? Explain on page 9 or attach additional pages as needed.
YES NO
45. Has the applicant or any of its employees ever been charged with, or convicted of a crime other than
minor traffic violations? Explain on page 9 or attach additional pages as needed.
YES NO
46. Has the applicant or any of its employees ever been diagnosed or treated for alcoholism, drug
addiction, any chemical dependency, or mental or chronic physical illness? Explain on page 9 or
attach additional pages as needed.
YES NO
47. Has any claim or suit ever been made against the applicant OR any other person proposed for this
insurance? How Many? ______ (Complete Supplemental Claims form for Each.)
YES NO
48. Is the Applicant or any person proposed for this insurance aware of any act, error, omission, fact,
circumstance, or records request from any attorney which may result claim or suit?
If yes, please explain in detail, completing a supplemental claim form for each.
YES NO
49. Has any claim or suit been made against the Applicant or any person proposed for this insurance that
has not been reported to the Applicant’s current or prior insurer? If yes, please explain in detail,
completing a supplemental claim form for each.
YES NO
CLAIMS AND HISTORY – Please explain or complete a supplemental claim for form for all “Yes” answers.
Page 9 of 11
NOTICE TO ALABAMA, ALASKA, ARIZONA, ARKANSAS, CALIFORNIA, CONNECTICUT, DELAWARE, GEORGIA, IDAHO, ILLINOIS, INDIANA, IOWA, KANSAS, MARYLAND,
MASSACHUSETTS, MICHIGAN, MINNESOTA, MISSISSIPPI, MISSOURI, MONTANA, NEBRASKA, NEVADA, NEW HAMPSHIRE, NORTH CAROLINA, NORTH DAKOTA,
OREGON, RHODE ISLAND, SOUTH CAROLINA, SOUTH DAKOTA, TEXAS, UTAH, VERMONT, WASHINGTON, WEST VIRGINIA, WISCONSIN, AND WYOMING APPLICANTS:
In some states, 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, for the purpose of misleading, conceals information concerning any fact material thereto, may commit a fraudulent
insurance act which is a crime in many states.
NOTICE TO COLORADO APPLICANTS: 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 policy holder or claimant for the purpose of defrauding
or attempting to defraud the policyholder or claiming with regard to a settlement or award payable for insurance proceeds shall be reported to the Colorado Division
of Insurance within the Department of Regulatory Agencies.
NOTICE TO DISTRICT OF COLUMBIA APPLICANTS: WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the
insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to
a claim was provided by the applicant.
NOTICE TO FLORIDA APPLICANTS: Any person who knowingly and with intent to injure, defraud or deceive any insurance company files a statement of claim containing
any false, incomplete or misleading information is guilty of a felony of the third degree.
NOTICE TO HAWAII APPLICANTS: For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or benefit is a
crime punishable by fines or imprisonment, or both.
NOTICE TO KENTUCKY APPLICANTS: 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.
NOTICE TO LOUISIANA APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false
information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
NOTICE TO MAINE APPLICANTS: 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 denial of insurance benefits.
NOTICE TO NEW JERSEY APPLICANTS: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and
civil penalties.
NOTICE TO NEW MEXICO APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false
information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties.
FRAUD WARNING
SUPPLEMENTAL INFORMATION (reference question number if applicable)
Page 10 of 11
NOTICE TO NEW YORK APPLICANTS: Any person who knowingly and with intent to defraud an 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 also be subject to a civil penalty not to exceed $5,000 and the stated value of the claim for each such violation.
NOTICE TO OHIO APPLICANTS: Any person who, with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an application or files
a claim containing a false or deceptive statement is guilty of insurance fraud.
NOTICE TO OKLAHOMA APPLICANTS: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes a any claim for the
proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.
NOTICE TO PENNSYLVANIA APPLICANTS: Any person who knowingly and with intent to defraud any insurance company, or other person, files an application for
insurance or statement of a 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 the person to criminal and civil penalties.
NOTICE TO TENNESSEE APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of
defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.
NOTICE TO VIRGINIA APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding
the company. Penalties include imprisonment, fines and denial of insurance benefits.
The Applicant acknowledges that the answers provided herein are based on a reasonable inquiry and/or investigation. The Applicant warrants that the above
statements and particulars together with any attached or appended documents are true and complete and do not misrepresent, misstate or omit any material facts.
The Applicant agrees to notify us of any material changes in the answers to the questions on this questionnaire which may arise prior to the effective date of any
policy issued pursuant to this questionnaire and the Applicant understands that any outstanding quotations may be modified or withdrawn based upon such
changes at our sole discretion. Completion of this form does not bind coverage. Applicant’s acceptance of the company’s quotation is required prior to binding
coverage and policy issuance. All written statements and materials furnished to the company in conjunction with this application are hereby incorporated by
reference into this application and made a part of this application.
Applicant: _______________________________________ Title:
FEIN #: _________________________________________
Applicants Signature: _______________________________ _____ Date:
Agent/Broker Name:
Page 11 of 11
If reporting more than one claim or incident, please photocopy and complete a separate form for each. Attach additional
sheets if necessary for adequate explanation. All questions must be answered or marked Not Applicable (N/A), and each
sheet must be signed.
Name of Patient:____________________________________________ Age:______ Sex:_______
Incident Claim
Date reported to insurance company: ______________
Name of insurance company: _______________________________________________
Date of incident and your treatment: __________________________________________________________
Allegations / Circumstances: ___________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Additional Defendants: _______________________________________________________________________
What is the present condition of the patient?______________________________________________________
___________________________________________________________________________________________
STATUS OF CLAIM
Suit threatened, no action taken Court outcome in YOUR favor: Unresolved/Open
Suit filed but dropped by claimant Jury verdict Awaiting mediation
Summary judgment in your favor Directed verdict Awaiting court action
Reserve amount:
$__________________
Suit settled out of court Court outcome in favor of plaintiff:
a. Date claim paid: _____________ Jury verdict
b. Amount paid: $_____________ Directed verdict
c. Did you want to settle? Amount of loss payment:
Yes No $_____________________
Name and address of the attorney assigned to your case: ____________________________________________
___________________________________________________________________________________________
To your knowledge, was any settlement paid by another party involved (i.e., your P.A., P.C., partners, employees, etc.)?
Yes: No:
Explain in detail what action(s) you have taken to prevent recurrence of this type of claim:
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Signature: __________________________________ Date:_____________________
Printed Name: __________________________________
SUPPLEMENTAL CLAIM / INCIDENT INFORMATION
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

AH HOME HEALTH And MEDICAL STAFFING 1 (Kinsale Insurance)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 16 July 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document