Fillable AH MEDICAL ARTS SCHOOL 1 (Kinsale Insurance)

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AH MEDICAL ARTS SCHOOL 1 (Kinsale Insurance)

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  • 175 check-boxes
  • 233 other fields

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Page 1 of 10
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:
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 – MEDICAL ARTS SCHOOL
Page 2 of 10
MEDICAL ARTS SCHOOL 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
- Copy of each course curriculum
1. Full name of Applicant (Including DBA’s) ___________________________________________________________________
8. Date Established _____________________ Years under current management _____________
9. Applicant is a:
Individual
Professional Associations
Corporation
Partnership
LLC
Joint Venture
Other:____________________________________
GENERAL INFORMATION
2. Mailing Address:______________________________________________________________________________________
STREET CITY COUNTY STATE ZIP
3. Location Address: Check here if same as mailing:
(1) ____________________________________________________________________________________
STREET CITY COUNTY STATE ZIP
(2) ____________________________________________________________________________________
STREET CITY COUNTY STATE ZIP
(3) ____________________________________________________________________________________
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:
Kinsale Insurance Company
P. O. Box 17008
Richmond, VA 23226
(804) 289-1300
www.kinsaleins.com
Page 3 of 10
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. Please describe in detail the nature of the applicant’s operation and types of services rendered.
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
13. Please state sources and amounts of total revenue:
Source Last 12 months Next 12 months
Charitable contributions $________________ $_________________
Government Funding $________________ $_________________
Fee for services $________________ $_________________
Other (Specify) $________________ $_________________
Total Gross Revenue $________________ $_________________
14. Are you:
Licensed and certified as required by state and/or federal law? Yes No
Licensed and approved by State Board of Health? Yes No
A member of a state or national association? Yes No
If yes, which one(s) _____________________________________________________________________
15. Provide a breakdown of average annual student attendees by category:
Students
Number of Each
EMT Basic
EMT Intermediate
EMT Advanced/Paramedic
LVN/LPN
RN
Other (Specify):_______________________
Other (Specify):_______________________
Other (Specify):_______________________
Age of students: _____0-18 _____19-39 _____40-65 _____Over 65
OPERATIONS
Page 4 of 10
16. Does the insured operate any outpatient clinic or other operations as part of the curriculum? Yes No
If yes, describe services provided:________________________________________________________
___________________________________________________________________________________
17. Average length of classes instructed: _____________________________________________________
18. Are externship programs offered? Yes No
If yes:
a. Does the applicant provide staff instruction to supervise students in the program? Yes No
b. Provide a copy of contracts with the facilities where the programs are conducted.
c. Describe all externship programs offered: ______________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
19. Does applicant have incident reporting procedures in place? Yes No
20. Do you have a plan for medical emergencies? Yes No
21. Please indicate the number of employed and contracted staff/instructors by type:
Profession
Employed
Contracted
Full Time
Part Time
Full Time
Part Time
EMT
Paramedic
Nurses (RN, LPN/LVN)
Counselors/Social Workers
Students/Volunteers
Other
(Specify):_________________
Other
(Specify):_________________
Other
(Specify):_________________
22. a. Are all above individuals licensed in accordance with applicable state Yes No
and federal regulations?
If no, please explain. _______________________________________
b. Do you require contracted staff to carry their own professional liability insurance? Yes No
STAFF
Page 5 of 10
23. Please provide name and qualifications of Medical Director
24. Please indicate all of the hiring/screening procedures used for professionals and paraprofessionals who provide patient care
services at your facility:
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?
25. Does your staff employment application include questions about whether the individual Yes No
convicted for any crime, including sex-related or child-abuse related offenses?
26. Do you have a written procedure for dealing with sexual abuse? Yes No
If yes, please attach a copy.
27. Do you have a plan of supervision that monitors staff in day-to-day relationships Yes No
with clients?
28. Do you currently carry coverage for abuse or molestation? Yes No
If yes, provide details including currently carried limits.
GENERAL LIABILITY - complete only if you are requesting GL coverage
29. 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
ABUSE AND MOLESTATION
30. Do any of the Applicant’s locations have any (explain any “yes” answers on page 6):
a. Exposure to flammables, explosive, chemicals? Yes No
b. Catastrophe exposure? Yes No
c. Exposure to radioactive materials? Yes No
31. Please describe all bodies of water on the premises (including pools), their use, and safeguards currently in place.
Page 6 of 10
32. Please list professional liability insurance carried for each of the past five years.
Insurer
Dates covered
Limits of Liability
Per claim/ Aggregate
Deductible
Premium
Retroactive
date
33. 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/ Aggregate
Deductible
Premium
Occurrence or
Claims Made
If the current expiring GL policy is claims-made, what is the retroactive date? _____________
Provide details for all “yes” answers to questions 34-41 on page 7 or attach additional pages as needed.
COVERAGE HISTORY AND LOSS HISTORY
34. Has the applicant or any of its employees ever had any professional license or license to prescribe and/ or
dispense narcotics limited, suspended, revoked, denied, or investigated by any licensing board or
regulatory agency?
Yes No
35. Has the applicant or any of its employees ever been charged with, or convicted of a crime other than minor
traffic violation?
Yes No
36. 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?
Yes No
37. Has any insurance company ever rescinded, cancelled, non-renewed, or declined any similar insurance for
the applicant? If yes, please provide a detailed explanation.
Yes No
38. Has any claim or suit ever been made against the applicant OR any other person proposed for this
insurance? (Complete Supplemental Claims form for Each)
Yes No
Page 7 of 10
SUPPLEMENTAL INFORMATION Use the remainder of this page as needed or to address questions referenced within the application
39. Have there been any claims or do you have knowledge of information which might reasonably be expected
to give rise to a claim of physical abuse or molestation?
Yes No
40. Is the applicant or any person proposed for this insurance aware of any known losses or claims that have
not been reported to a prior insurance carrier or any other source from which payment might be made?
(Complete Supplemental Claims form for Each)
Yes No
41. 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 in a claim or suit? (Complete
Supplemental Claims form for Each)
Yes No
Page 8 of 10
FRAUD WARNING
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.
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.
Page 9 of 10
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 #: _________________________________________
Applicant’s Signature: _____________________________ Date:
Agent/Broker Name:
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Page 10 of 10
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
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AH MEDICAL ARTS SCHOOL 1 (Kinsale Insurance)

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Completed 16 July 2020

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