Fillable AH New Business Residential Application (Kinsale Insurance)

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AH New Business Residential Application (Kinsale Insurance)

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  • 280 check-boxes
  • 391 other fields

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Page 1 of 12
NEW BUSINESS RESIDENTIAL OPERATIONS 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 current General Liability and Professional Liability insurance Declarations Page
5-year previous carrier loss runs, valued within the last 45 days
Copies of State Inspections, Complaint Investigations, and Facility License for each facility
1) Full name of Applicant (Including DBA’s) ___________________________________________________________________
2) Mailing Address:______________________________________________________________________________________
STREET CITY COUNTY STATE ZIP
3) Location Address: Check here if same as mailing: - Please list additional locations on PAGE 10
(1)____________________________________________________________________________________
STREET CITY COUNTY STATE ZIP
(2)____________________________________________________________________________________
STREET CITY COUNTY STATE ZIP
(3)____________________________________________________________________________________
STREET CITY COUNTY STATE ZIP
(4)____________________________________________________________________________________
STREET CITY COUNTY STATE ZIP
4) Website Address: www._______________________________
5) Telephone:_____________________________________
6) Date Established: _____________________
7) Years Under Current Management: _________________
8) Inspection/Audit Contact Name & E-mail: _____________________________________________________________________
9) Enterprise is: For Profit Not For Profit
10) Applicant is a:
Individual
Professional Associations
Corporation
Partnership
LLC
Joint Venture
Other
SECTION I - GENERAL INFORMATION – TO BE COMPLETED BY ALL APPLICANTS
Kinsale Insurance Company
P. O. Box 17008
Richmond, VA 23226
(804) 289-1300
www.kinsaleins.com
Page 2 of 12
Facility classification and bed census:
Total # of
Occupied
Beds:
Applicant Section
Reference Note:
Skilled Nursing & Intermediate Care
________
(Please complete Section A below)
Assisted Living
________
(Please complete Section A below)
Assisted Living – Memory Care
________
(Please complete Section A below)
Elderly Independent Living
________
(Please complete Section A below)
Home for Persons with Mental and Physical Disabilities
________
(Please complete Section B below)
Youth Group Home
________
(Please complete Section B below)
Other Group Home / Shelter / Halfway House
(Not Substance Abuse Related)
________
(Please complete Section B below)
Substance Abuse Detox/Rehab/Sober Living
________
(Please complete Section C below)
Other (Please Specify): ______________
________
(Please complete the most relevant
Section(s) below)
Section II Operations - Sections A-C Instructions:
Complete each and every section that applies to the applicant’s operations below.
Each section is clearly marked with the type of operation which corresponds with the facility classifications described above.
If a section does not apply to the applicant’s operation, the applicant is required to mark the N/A box in order to consider that
section complete.
11) Is this entity owned by, associated with, or controlled by any other entity? Yes No
If yes, please provide details:
____________________________________________________________________________________________________________
12) Please state sources and amounts of total revenue:
Last 12 months
Next 12 months
Medicare
$_________________
$_________________
Medicaid
$_________________
$_________________
Charitable
$_________________
$_________________
Private Pay
$_________________
$_________________
Total Gross Revenue
$_________________
$_________________
13) Please describe in detail the nature of the applicant’s operation and types of services rendered:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
14) What type(s) of state issued license(s) does the applicant carry? ____________________________________________________
SECTION II - OPERATIONS – TO BE COMPLETED BY ALL APPLICANTS
Page 3 of 12
Mark N/A if this section does not apply to the applicant. N/A
Resident Census
Location 1
Location 2
Location 3
Number of Licensed beds
Number of Occupied beds
Number of Independently Ambulatory
Number of Wheelchair Bound (all or most of the day)
Number of Bedridden Residents
Number of Dementia Residents
Number of Alzheimer’s residents:
Stage 1: No impairment through Stage 5: Moderately Severe Decline
Number of Alzheimer’s residents:
Stage 6: Severe Decline through Stage 7: Very Severe Decline
Residents in each age range:
If any residents are under 60, please provide details of medical conditions
requiring Long Term Care: ________________________________________
______________________________________________________________
___ 0-17
___ 18-59
___ 60-74
___ 75-84
___ 85+
___ 0-17
___ 18-59
___ 60-74
___ 75-84
___ 85+
___ 0-17
___ 18-59
___ 60-74
___ 75-84
___ 85+
15) Do you provide care for any residents with the following condition:
Yes No Traumatic Brain Injury
Yes No Chemical Dependency
Yes No Tube Feeding
Yes No Ventilator/Tracheostomy services
Yes No Psychiatric / Sociopathic / Schizophrenic
If yes, please explain: ____________________________________________________________________________________
16) Do you have an internal wound care team or outside wound care consultant?
If yes, provide the name and start date of the Consultant _______________________________________
Yes No
17) Bedsore Information: Reporting Date: _____/_______/_______ State “None”, if none: _________
Bedsore Stage
Acquired in Facility
Inherited from Another Location
Stage I or II
Stage III
Stage IV
18) Are Adult Day Care services offered to non-residents Yes No , if Yes provide the following information:
a. Total Number of licensed slots:________________
b. Average Daily Participants:___________________
c. Any overnight stays? Yes No
If yes, please explain:____________________________________________________________________
d. Do you provide transportation to or from? Yes No
SECTION A – Elderly Independent / Assisted / Skilled Nursing Residential Facility Owners/Operators Complete
Page 4 of 12
19) Are call buttons or pull cords provided in each resident’s room?
Direct 911 Notification
Yes No
Third Party Monitoring
If yes, Third Party Name _______________________________________
Yes No
Front Desk Notification
If yes, response protocol ______________________________________
Yes No
Hall Light / Alarm
Yes No
Does the resident agreement include Pull cord/call button protocols
Yes No
Yes No
20) Are handrails installed in hallways and bathrooms?
Yes No
21) Do tubs and showers have non-slip surfaces installed?
Yes No
22) Do individual units have cooking appliances (excluding microwaves)?
If “Yes,” check type: Gas Electric
Yes No
23) Are home health or hospice services contracted directly through the:
Resident
Facility - Provider name ____________________________________(attach certificate of insurance)
Any affiliation to the Provider?
Yes No
24) Does the facility have the right to transfer a resident whose needs exceed the services of the facility?
Yes No
25) What are the written guidelines to determine when a resident no longer qualifies for services?
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
Page 5 of 12
Mark N/A if this section does not apply to the applicant. N/A
Resident Census
Location 1
Location 2
Location 3
Number of Licensed beds
Number of Occupied beds
Number of Male residents
Number of Female residents
Number of Independently Ambulatory
Number of Wheelchair bound
Number of Bedridden residents
Number of Severely/Profoundly Retarded
Number of Mild/Moderately Retarded
Number of Halfway House / Abused & Battered / Homeless Shelter
Number of Troubled Youth
Number of Foster Care / Transitional Youth
Other Specify):___________________________________________
Indicate number of residents in each age range:
____ 0-17
____ 18-59
____ 60-74
____ 0-17
____ 18-59
____ 60-74
____ 0-17
____ 18-59
____ 60-74
26) Do you provide care for any residents with the following condition/contraints:
Yes No Traumatic Brain Injury
Yes No Chemical Dependency
Yes No Tube Feeding
Yes No Ventilator/Tracheostomy services
Yes No Psychiatric / Sociopathic / Schizophrenic
Yes No Individual Locked Units:_________
If yes, please explain: ____________________________________________________________________________________
27) Are male and female residents separated by floor, building or other means?
If no, please explain ___________________________________________________
Yes No
28) Are minor and adult residents separated by floor, building or other means?
If no, please explain _____________________________________________
Yes No
29) Please list any contracts in place with governmental entities: ____________________________________________________
30) Explain any court supervision, juvenile detention, probation, parole, or correctional exposure and restraint procedures:
____________________________________________________________________________________________________
____________________________________________________________________________________________________
SECTION B - Other Group Homes (Non-Elderly) Residential Facility Owners/Operators Must Complete
Page 6 of 12
Mark N/A if this section does not apply to the applicant. N/A
Resident Census
# detox
beds
# non-detox
beds
Avg length
of stay
Early Intervention – Level (0.50)
Outpatient Services – Level (1.00)
Intensive Outpatient / Partial Hospitalization - Level (2.1 – 2.50)
Clinically Managed Low-Intensity Residential Services – Level (3.10)
Clinically Managed High-Intensity Residential Services – Level (3.30)
Clinically Managed Medium-Intensity Residential Services – Level (3.50)
Medically Monitored High-Intensity Inpatient Services – Level (3.70)
Medically Managed Intensive Inpatient Services – Level (4.00)
Sober living ONLY (No medical services on-site)
Other (Please Specify):____________________________________________
Indicate number of residents in each age range:
____ 0-17
____ 18-59
____ 60-74
____ 0-17
____ 18-59
____ 60-74
____ 0-17
____ 18-59
____ 60-74
31) Are residents required to be detoxed and sober prior to admission?
If yes, how is this documented? ______________________________________________________________
If yes, what is the minimum duration of sobriety required?
Less than 72 hours
More than 72 hours
More than 7 days
More than 14 days
More than 30 days
Yes No
32) Does any insured perform any “rapid detox” or any detox under general anesthesia?
Yes No
33) Do any residents receive methadone, suboxone, or similar? If yes, how many? _______________________
Yes No
34) Do the intake procedures include drug tests and blood tests?
Is a licensed employee responsible for intake and approving residents?
If yes, provide the name and license designation for that employee _________________________________
Yes No
Yes No
35) What is the average length of stay for each resident? ____________________________________________
36) Has ANY resident died at the facility in the last 24 months? If yes, provide comprehensive details. (Use the
supplement information sheet if more space is needed). __________________________________________
________________________________________________________________________________________
Yes No
37) Does any insured have any contractual relationship or ownership interest with any other substance abuse
operation? If yes, please explain? ____________________________________________________________
________________________________________________________________________________________
Yes No
SECTION C - Substance Abuse / Rehab / Sober Living Residential Facility Owners/Operators Complete
Page 7 of 12
Description
Location 1
Location 2
Location 3
Location 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
38) Do any of the Applicant’s locations have any:
a. Exposure to flammables, explosive, chemicals?
b. Catastrophe exposure?
c. Exposure to radioactive materials?
If yes, Please explain: ___________________________________________________________________
Yes No
Yes No
Yes No
Staff Census
How many
Employed
How many
Contracted
Insured
Elsewhere?
Coverage
Requested?
Administrators
Yes No
Yes No
Physicians
Yes No
Yes No
Physician Assistant
Yes No
Yes No
DON/ADON
Yes No
Yes No
Nurses (NP, RN, LPN)
Yes No
Yes No
Nurse Aides
Yes No
Yes No
Resident Assistants
Yes No
Yes No
Psychiatrists
Yes No
Yes No
Psychologists
Yes No
Yes No
Social Workers
Yes No
Yes No
Therapists (PT/OT/ST/DT)
Yes No
Yes No
Students/Volunteers
Yes No
Yes No
Pharmacists
Yes No
Yes No
Other (Specify):________________________
Yes No
Yes No
39) Please provide the name and qualifications of the medical director:_________________________________________________
40) Are all above individuals licensed in accordance with applicable state and federal regulations?
Yes No
41) Do you require contracted staff to carry their own professional liability insurance?
Yes No
42) What is the staff turnover ratio? ________%
43) 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)
44) Does the facility maintain 24 hour awake staff? Provide your 8 or 12 hour shift staff to resident ratio:
8 Hour Shift Structure
Staff : Resident Ratio
12 Hour Shift Structure
Staff : Resident Ratio
7:00am – 3:00pm
7:00am – 7:00pm
3:00pm – 11:00pm
7:00pm – 7:00am
11:00pm – 7:00am
Yes No
SECTION IV - STAFF – TO BE COMPLETED BY ALL APPLICANTS
SECTION III - PREMISES INFORMATION – TO BE COMPLETED BY ALL APPLICANTS
Page 8 of 12
45) Does a qualified licensed medical professional conduct assessments for all new residents?
If yes, provide name and designation of the medical professional __________________________________
Years of experience in position? ______________ Years of experience in the facility? __________________
Mark which of the following are included in the resident assessment:
History of prior illness and injuries
Current medications
Disorientation / Cognition Limitations
History of Wandering / Elopement
Mobility limitations / Required assistance
History of falls
Skin Assessment
Combativeness
Psychiatric history
Yes No
46) Provide the name & years of experience for the following:
a. Director of Nursing ________________________________ Years of experience ________________
b. Facility Administrator_______________________________ Years of experience ________________
47) Do you accept residents who are considered a threat to themselves or others?
Yes No
48) Do you have now or ever had a resident that has threatened, attempted, or committed suicide?
If yes, explain ______________________________________________________________________________
Yes No
49) Is a current physical required for admission?
How often is the care plan updated? ___________________________________________________________
Yes No
50) Does each resident have their own attending physician?
If no, who performs the attending physician role? _________________________________________________
Yes No
51) Do any third-party providers render services at any of your locations?
If yes, please explain ________________________________________________________________________
Yes No
52) Do you provide any day services or other services to non-residents whether onsite or offsite?
If yes, please explain ________________________________________________________________________
Yes No
53) Do any insureds’ have any live-in family members on premise, or provide any direct care to family members at
the facility? If yes, how many? _________ Please explain __________________________________________
Yes No
54) Are residents allowed to leave the premises unattended?
Yes No
55) What precautions are used to keep track of residents?
Sign out procedure Bed checks
All exit doors alarmed Locked unit for residents prone to wandering
Other (Please describe): ______________________________________________________________
56) Have any residents eloped from your facility in the past 3 years?
If yes, how many? ________ Details? ___________________________________________________________
Yes No
57) In the past 24 months has any resident fallen and suffered a fracture, been hospitalized or died as a result of
the fall? If yes, please provide details (attach additional pages as needed):
Yes No
Resident name:
Date of fall:
Injury:
Current Condition
Current Location:
58) Are medications administered by staff? If yes, by whom ______________________Licensed as:_____________
Are the medications kept in a locked area?
Yes No
Yes No
SECTION VI - MONITORING AND RISK MANAGEMENT – TO BE COMPLETED BY ALL APPLICANTS
SECTION V - ADMISSION POLICIES – TO BE COMPLETED BY ALL APPLICANTS
Page 9 of 12
59) Are there an “incident reporting” procedures in place?
If yes, are all incident reports reviewed by the risk manager and medical director?
Yes No
Yes No
60) Are resident records kept for the entirety of the resident’s stay and a minimum of 2 years after they leave?
If no, please explain? ________________________________________________________________________
Yes No
61) Is this a non-smoking facility? If no, what is smoking policy:__________________________________________
Yes No
62) Please describe any onsite bodies of water (pool/lake/pond/ocean), animal(s), or other activities (trampoline/ropes course)
________________________________________________________________________________________________________
63) State Inspection: (Please attach copies of State Inspections & Complaint Investigations for the last 36 months)
Total # of State Inspection, Surveys or Complaint Investigations in the last 36 months?
_______________
Total # of Deficiencies:
_______________
Were all Corrective Action Plans accepted by State:
Yes No
Total # of substantiated complaints:
_______________
Total # of Fines in the last 2 years:
_______________
Please list Professional Liability insurance carried for each of the past three years:
Professional Liability Claims Made Retroactive Date? _____________
Insurer
Dates covered
Limits of Liability
Per claim/ Agg
Deductible
Premium
Occurrence or
Claims – Made?
Please list General Liability insurance carried for each of the past three years:
General Liability Claims Made Retroactive Date? _________________
Insurer
Dates covered
Limits of Liability
Per claim/ Agg
Deductible
Premium
Occurrence or
Claims – Made?
64) Has the applicant or any of its employees ever had any professional license or license to prescribe and or
dispense narcotic ever been limited, suspended, revoked, denied, or investigated by any licensing board or
regulatory agency?
Yes No
65) Has the applicant or any of its employees ever been charged with, or convicted of a crime other than minor
traffic violation?
Yes No
66) 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
67) 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
68) 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
69) 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
70) Is the applicant or any person proposed for in 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
71) 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
PROVIDE DETAILS FOR ALL “YES” ANSWERS TO QUESTIONS 64-71 IN THE SUPPLEMENTAL INFORMATION SECTION AND/OR THE
SUPPLEMENT CLAIM FORM ATTACHED BELOW - ATTACH ADDITIONAL PAGES AS NEEDED
SECTION VII - COVERAGE AND LOSS HISTORY – TO BE COMPLETED BY ALL APPLICANTS
Page 10 of 12
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.
SUPPLEMENTAL INFORMATION
Use the remainder of this page as needed or to address questions referenced within the application
FRAUD WARNING
Page 11 of 12
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.
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:
_____________________________________________________________________
Page 12 of 12
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 takenCourt 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 courtCourt 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 New Business Residential Application (Kinsale Insurance)

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Completed 16 July 2020

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