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AH MISC SOCIAL SERVICES (Kinsale Insurance)

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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 – MISCELLANEOUS SOCIAL SERVICES
Page 2 of 10
MISCELLANEOUS SOCIAL SERVICES 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
1. Full name of Applicant (Including DBA’s)
Date Established ________________________ Years under current management
8. 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
(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:
Kinsale Insurance Company
P. O. Box 17008
Richmond, VA 23226
(804) 289-1300
www.kinsaleins.com
Page 3 of 10
9. Enterprise is: For Profit Not For Profit
10. Is this entity owned by, associated with or controlled by any other entity? Yes No
If yes, please give details
11. Please describe in detail the nature of the applicant’s operation and types of services rendered.
___________________________________________________________________________________________
_____________________________________________________________________________________
________________________________________________________________________________________
12. Do you operate any residential facilities? YES NO
If yes, please describe(additional supplement will be required)___________________________________________
___________________________________________________________________________________________
_____________________________________________________________________________________
13. Please indicate type of service:
Crisis Hotline Referral Agency
Food Bank Sheltered Workshop
Job Placement Vocational/Family Skills Training
Meals on Wheels Mental Health Counseling
Drug/ Alcohol Treatment Big Brother/ Big Sister or similar program
Rehabilitation Agency Other (Describe) _______________________
14. 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 REVENUES $________________ $_________________
15. Are medications dispensed? YES NO
If yes, are all medications kept in a secured, locked location with limited
key access? YES NO
OPERATIONS
Page 4 of 10
16. Please indicate estimated number of annual participants? __________________________
17. What percentage of clients are mentally or physically challenged? _______________%
18. What percentage of clients are elderly (above 55)? _______________%
19. What percentage of clients are under 18 years old _______________%
20. Does the insured offer any of the following medical services to include?
Free clinic
Physical rehabilitation
Skilled nursing care
Home health care
Other medical care (describe) __________________________________________________
21. Does your staff employment application include questions about whether the individual has been convicted for
any crime, including sex-related or child-abuse related offenses?
YES NO
22. Do you have a written procedure for dealing with sexual abuse? YES NO
23. Do you have a plan of supervision that monitors staff in day-to-day relationships
with clients? YES NO
24. Do you currently carry coverage for abuse or molestation? YES NO
If yes, provide details ________________________________________________
ABUSE AND MOLESTATION
Page 5 of 10
25. Please indicate the number of employed and contracted staff by type:
Number Employed?
Number Contracted
Insured
Elsewhere?
Coverage
Desired?
Full Time
Part Time
Full Time
Part Time
Acupuncturists
YES NO
YES NO
Chiropractors*
YES NO
YES NO
Counselors
YES NO
YES NO
Dentists*
YES NO
YES NO
Inhalation/ Respiratory Therapists
YES NO
YES NO
Laboratory Technicians
YES NO
YES NO
Licensed Practical Nurses
YES NO
YES NO
Nurse Anesthetists
YES NO
YES NO
Nurse Midwives*
YES NO
YES NO
Nurse Practitioner
YES NO
YES NO
Opticians
YES NO
YES NO
Optometrists
YES NO
YES NO
Paramedics/ EMT’s
YES NO
YES NO
Perfusionists
YES NO
YES NO
Pharmacists
YES NO
YES NO
Physician Assistant
YES NO
YES NO
Physicians – Major Surgery*
YES NO
YES NO
Physicians – Minor surgery*
YES NO
YES NO
Physicians – No surgery*
YES NO
YES NO
Physicians – OBGYN*
YES NO
YES NO
Physiotherapists
YES NO
YES NO
Psychologist
YES NO
YES NO
Registered Nurses
YES NO
YES NO
Social Workers
YES NO
YES NO
Speech Therapists
YES NO
YES NO
X-ray Technicians
YES NO
YES NO
Other: (Specify)
YES NO
YES NO
26. Are all of the above:
a. Individuals licensed in accordance with applicable state and federal YES NO
regulations?
If no, please explain. _______________________________________
b. Do you require contracted staff to carry their own professional liability insurance? YES NO
27. Does the insured have any physicians as employed staff members? YES NO
If yes, are they required to carry their own malpractice insurance? YES NO
What Limits? __________________________________________
STAFF
Page 6 of 10
28. 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?
COVERAGE HISTORY AND LOSS HISTORY
29. 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
30. 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 30-38 on page 6 or attach additional pages as needed.
31. 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
32. Has the applicant or any of its employees ever been charged with, or convicted of a crime other than
minor traffic violation?
YES NO
Page 7 of 10
GENERAL LIABILITY - complete only if you are requesting GL coverage
39. 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
33. 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
34. 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
35. Has any claims or suit ever been made against the applicant OR any other person proposed for this
insurance? (Complete Supplemental Claims form for Each.)
36. 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
37. 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
38. 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
40. Do any of the Applicant’s locations have any (explain any “yes” answers on page 6):
a. Exposure to flammables, explosive, chemicals?
b. Catastrophe exposure?
c. Exposure to radioactive materials?
YES NO
YES NO
YES NO
41. Has any claim for General Liability ever been made against any person(s) or entity(ies) proposed for
this insurance? If Yes, answer complete supplemental claims form for each.
YES NO
42. Is (are) any person(s) or entity(ies) proposed for this insurance aware of an fact, circumstance or
situation which may result in a General Liability claim, such that would fall under the proposed
insurance? If Yes, answer complete supplemental claims form for each.
YES NO
Page 8 of 10
SUPPLEMENTAL INFORMATION Use the remainder of this page as needed or to address questions referenced within the application
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.
Page 9 of 10
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.
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:
____________________________________________________________________________
click to sign
signature
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Page 10 of 10
SUPPLEMENTAL CLAIM/INCIDENT INFORMATION
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: __________________________________
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AH MISC SOCIAL SERVICES (Kinsale Insurance)

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Completed 16 July 2020

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