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Allied Healthcare Professional and General Liability

Product

AH APP 8/12 - USLI

page 1 of 5

This is an application for a claims made (professional) and occurrence (general liability) policy. Please read your policy carefully.

Defense costs shall be applied against the deductible.

Section i. ProfeSSional liability Underwriting information

Name of applicant: ____________________________________________________________ DBA: ________________________________________

Location address: _________________________________________________________________________ q Same as mailing address

City: ___________________________________________________________________

State: ________ Zip:__________________________

Web address: _____________________________E-mail address of primary contact: __________________________Number of locations_______

Percent of services rendered outside the U.S., if any _______% Annual revenue_____________________________________________________

Independent contractor means an individual who performs professional services for others and receives an IRS Form 1099 for compensation paid.

Part Time means less than 1,000 hours worked per year.

1. Provide a detailed description of the nature of applicant’s operation and services provided:

__________________________________________________________________________________________________________________________

2. Is the applicant seeking coverage for independent contractors? q Yes q No

a)Does the applicant verify that all independent contractors working on their behalf maintain professional

liability and commercial general liability insurance with general liability limits equal to or greater than the

limits of professional liability insurance purchased? q Yes q No q Not applicable

If “No,” explain _________________________________________________________________________________________________________

3. Has any professional(s) seeking coverage been providing their services less than three years? q Yes q No

If “Yes,” detail experience and qualifications ___________________________________________________________________________________

__________________________________________________________________________________________________________________________

4. Do all professionals listed above, for whom coverage is sought, have a current, unrestricted professional license or

its equivalent as required under federal or state law and/or the rules and regulations of the profession. q Yes q No q Not applicable

5. List professional license(s) and degree(s) or equivalents held by each professional listed above:

__________________________________________________________________________________________________________________________

6. Is applicant controlled, owned, affiliated or associated with any firm, corporation or company not identified in this application? q Yes q No

If “Yes,” please provide details ______________________________________________________________________________________________

7. Does the applicant have any subsidiaries for which coverage is sought? q Yes q No

If “Yes,” please provide the name, percentage owned and professional classification of each subsidiary and include them in the list of ___

professions above: ________________________________________________________________________________________________________

Type of professional (i.e. massage therapist, mental

health counselor, physical therapist.. etc.)

Employees/Owners/

Partners/Self Employed

Independent Contractors (even if

coverage is not desired for them)

Full Time

Part Time Full Time

Part Time

USLI.COM

888-523-5545

Submit Application

8. Do any professionals for whom coverage is sought provide, practice, perform, administer or assist in any

of the following now or expect to in the next 12 months:

a) Surgery or surgical procedures including pre-operative and post operative procedures? q Yes q No

b) Injections of any kind? q Yes q No

c) Diagnosing conditions, disorders or diseases in patients? q Yes q No

d) Services as a physician, surgeon, nurse, anesthetist, anesthesiologist, psychiatrist, chiropractor,

acupuncturist, pharmacist or dentist? q Yes q No

e) Overnight services? q Yes q No

f) Designing, testing, selling, distributing or manufacturing products of any kind including vitamins, minerals, herbal,

medicinal or nutritional supplements? q Yes q No

g) More than twenty five percent of services involving the transportation of clients/patients? q Yes q No

h) Prescribing, monitoring or dispensing medication, equipment, or devices? q Yes q No

i) Provide professional services within any prison/correctional facility or for any probation or prison release program? q Yes q No

j) Hospice care? q Yes q No

k) Medical healthcare services (including but not limited to monitoring blood pressure, changing dressings, q Yes q No

monitoring respiration rates)?

l) Provide more than ten percent of services within a nursing home(s), or hospital? q Yes q No

If “Yes” to any of the above, describe service(s) provided and percentage of patients/clients receiving each service(s):

______________________________________________________________________________________________________________________________

9. Are criminal background checks and license verifications conducted for all professionals? q Yes q No

10. Does the applicant obtain a written informed consent from parents/guardians of minors

receiving services? q In all cases q Sometimes q Never

11. List additional insured(s) required by contract to be included for professional liability coverage:

Attach a statement of details for all “Yes” answers to the following questions.

12. (a) Has the applicant or any professional listed above had a professional license or its equivalent

denied, revoked, restricted, suspended; been fined or disciplined in any way or been the subject of

any investigation by any authority for any reason, including but not limited to allegations of sexual abuse? q Yes q No

(b) Are any such actions pending as of the date of this application? q Yes q No

13. Has the applicant initiated litigation against any patients or clients in the past five years? q Yes q No

(if “Yes,” provide names, dates, status of litigation and demand amount)

14. In the past five years, has any claim been made or suit brought against the applicant, its predecessor(s) in

business or any of its present or former owners, partners, officers, directors, employees or independent contractors? q Yes q No

15. Is the applicant or any person proposed for this insurance aware of any circumstance, allegation, contention

or incident which may result in a claim being made against the applicant or any person proposed for this insurance? q Yes q No

16. Has any policy of professional liability insurance ever been cancelled or non-renewed by an insurance carrier? q Yes q No

(Not applicable in Missouri) If “Yes,” provide details__________________________________________________

17. (a) Does the applicant currently have professional liability insurance in force? q Yes q No

(b) Does the applicant currently have general liability insurance in force? q Yes q No

If “Yes,” specify:

(c) Number of years continuous, uninterrupted insurance coverage? Professional liability: _____________ General liability: _______________

18. Does applicant agree to maintain commercial general liability insurance? q Yes q No q Not applicable

If “No,” explain. _____________________________________________________________________________________________________________

Section ii. General liability UnderwritinG information (complete only if seeking this coverage)

1. Any general liability claims against applicant (paid, reserved or pending) in the past five years? q Yes q No

If “Yes,” please provide details. ____________________________________________________________________

2. Additional insured(s) to be included for general liability coverage:

AH APP 8/12 - USLI

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Name Address Relationship to Applicant

Name of

Professional Carrier

Limit Retroactive Date (if any) Deductible Annual Premium Policy Period Claims Made (C) or

Occurrence (O)

Name of General

Liability Carrier

Limit Retroactive Date (if any) Deductible Annual Premium Policy Period Claims Made (C) or

Occurrence (O)

Name Address Relationship to Applicant

3. Has any general liability policy been cancelled or non-renewed by an insurance carrier? q Yes q No (Not applicable in Missouri)

If “Yes,” provide details___________________________________________________________________________

4. Is the applicant the owner of the insured location? q Yes q No

If “Yes,” list all tenants of the building and the area of the portion occupied (if there are apartments, please indicate number of units)

Tenant Building area or number of apartment units

Section iii: ProPerty Section (Complete only if seeking this coverage)

1. Construction:

q Frame q Joisted masonry q Non-combustible q Masonry non-combustible

q Modified fire-resistive q Fire-resistive q Other ___________________

2. Protection class: ___________________

3. Requested cause of loss: q Basic q Special

4. Requested valuation: q Replacement cost q Actual cash value

5. Deductible:

q $1,000 q $2,500 q $5,000

6. Coinsurance: q 80% q 90% q 100%

7. Business personal property limit $ _____________________________

8. Business income with extra expense limit $

_____________________________________________

9. What year was the building constructed? _______________________

10. What is the square footage of the entire structure?

_______________sq. ft.

11. What is the square footage of the portion occupied by the applicant? _________ sq. ft.

12. Is the building fully protected by an operational sprinkler system covering 100% of the premises? q Yes q No

13. Age of roof ________yrs.

14. Roof type: q Flat q Wood shake q Shingle q Metal q Tile q Slate q Other _____________________

15. What Protection devices do you have on the premises? q Burglar Alarm q Fire Alarm q Central station q Local

16. Do you have Functional & Operating Smoke detectors? q Yes q No

17.

List your loss information for the past three years:

Property Coverages q None, or provide detail below:

Year Status Incurred Description

_______ Open/Closed $ ______________ _____________________________________________________________________________

18. Has your Insurance coverage been cancelled or non-renewed within the last three years? (not applicable in MO) q Yes q No

19. Have you gone bankrupt within the past three years? q Yes q No

20. For any building built prior to 1978, do any lack knob-and-tube or aluminum wiring on premises? q Yes q No

21. For any building built prior to 1978, is 100% of the wiring on functioning and operational circuit breakers q Yes q No

Section iV: aUto liability coVeraGe for Hired or non-owned aUtoS - (Complete only if seeking this coverage)

1. Does organization have a motor vehicle liability insurance policy in place? q Yes q No

Does organization own any motor vehicles or lease any motor vehicles on a long term basis (greater than 30 days)? q Yes q No

Does organization use hired or non-owned vehicles with passenger capacities exceeding 15 passengers? q Yes q No

4. Does organization use hired or non-owned vehicles for emergency medical transportation or emergency medical services? q Yes q No

5. Does organization transport non-ambulatory persons? q Yes q No

Does organization require evidence of insurance from employees, independent contractors and volunteers? q Yes q No

7. Does organization require a minimum of $100,000 CSL or $100,000/$300,000/$50,000 personal auto liability limits from employees,

independent contractors and volunteers? q Yes q No

8. Number of drivers: __________

9. Average driving frequency per week by drivers: q Once q 2-3 times q Daily

Section V: reqUired information

A. USLI application

B. Supplemental application (for select classes)

Arizona Notice: Misrepresentations, omissions, concealment of facts and incorrect statements shall prevent recovery under the policy only if

the misrepresentations, omissions, concealment of facts or incorrect statements are; fraudulent or material either to the acceptance of the risk,

or to the hazard assumed by the insurer or the insurer in good faith would either not have issued the policy, or would not have issued a policy

in as large an amount, or would not have provided coverage with respect to the hazard resulting in the loss, if the true facts had been made

known to the insurer as required either by the application for the policy or otherwise.

Colorado Fraud Statement: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company

for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and

civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts

or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard

to a settlement or award payable from insurance proceeds shall be reported to the Colorado division of insurance within the department of

AH APP 8/12 - USLI

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AH APP 8/12 - USLI

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regulatory agencies.

District of Columbia Fraud Statement: 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.

Florida Fraud Statement: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an

application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.

Florida Notice: (Applies only if policy is non-admitted) You are agreeing to place coverage in the surplus lines market. Superior coverage

may be available in the admitted market and at a lesser cost. Persons insured by surplus lines carriers are not protected under the Florida

Insurance Guaranty Act with respect to any right of recovery for the obligation of an insolvent unlicensed insurer.

Florida Fraud Statement: You are agreeing to place coverage in the surplus lines market. Superior coverage may be available in the

admitted market and at a lesser cost. Persons insured by surplus lines carriers are not protected under the Florida Insurance Guaranty Act with

respect to any right of recovery for the obligation of an insolvent unlicensed insurer.

Florida and Illinois Notice: I understand that there is no coverage for punitive damages assessed directly against an insured under Florida

and Illinois law. However, I also understand that punitive damages that are not assessed directly against an insured, also known as “vicariously

assessed punitive damages”, are insurable under Florida and Illinois law. Therefore, if any Policy is issued to the Applicant as a result of this

Application and such Policy provides coverage for punitive damages, I understand and acknowledge that the coverage for Claims brought in

the State of Florida and Illinois is limited to “vicariously assessed punitive damages” and that there is no coverage for directly assessed punitive

damages.

Kansas Fraud Statement: Any person who, knowingly and with intent to defraud, presents, causes to be presented or prepares with

knowledge or belief that it will be presented to or by an insurer, purported insurer, broker or any agent thereof, any written statement as part

of, or in support of, an application for the issuance of, or the rating of an insurance policy for personal or commercial insurance, or a claim for

payment or other benefit pursuant to an insurance policy for commercial or personal insurance which such person knows to contain materially

false information concerning any fact material thereto; or conceals, for the purpose of misleading, information concerning any fact material

thereto may be guilty of a crime and may be subject to fines and confinement in prison.

Kentucky Fraud Statement: 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.

Maine and Washington Fraud Statement: It is a crime to knowingly provide false, incomplete or misleading information to an insurance

company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits.

Maryland: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or

willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

Minnesota Notice: Authorization or agreement to bind the insurance may be withdrawn or modified only based on changes to the information

contained in this application prior to the effective date of the insurance applied for that may render inaccurate, untrue or incomplete any

statement made with a minimum of 10 days notice given to the insured prior to the effective date of cancellation when the contract has been in

effect for less than 90 days or is being canceled for nonpayment of premium.

New Jersey Fraud Statement: Any person who includes any false or misleading information on an application for an insurance policy is

subject to criminal and civil penalties.

New York Disclosure Notice: This policy is written on a claims made basis and shall provide no coverage for claims arising out of incidents,

occurrences or alleged Wrongful Acts or Wrongful Employment Acts that took place prior to retroactive date, if any, stated on the declarations.

This policy shall cover only those claims made against an insured while the policy remains in effect for incidents reported during the Policy

Period or any subsequent renewal of this Policy or any extended reporting period and all coverage under the policy ceases upon termination

of the policy except for the automatic extended reporting period coverage unless the insured purchases additional extend reporting period

coverage. The policy includes an automatic 60 day extended claims reporting period following the termination of this policy. The Insured may

purchase for an additional premium an additional extended reporting period of 12 months, 24 months or 36 months following the termination of

this policy. Potential coverage gaps may arise upon the expiration for this extended reporting period. During the first several years of a claims-

made relationship, claims-made rates are comparatively lower than occurrence rates. The insured can expect substantial annual premium

increases independent overall rate increases until the claims-made relationship has matured.

North Dakota Fraud Statement: Notice to North Dakota applicants – Any person who knowingly and with the intent to defraud and 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.

Ohio Fraud Statement: Any person who, with intent to defraud or knowing that he 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.

Ohio Notice: By acceptance of this policy, the Insured agrees the statements in the application (new or renewal) submitted to the company

are true and correct. It is understood and agreed that, to the extent permitted by law, the Company reserves the right to rescind this policy, or

any coverage provided herein, for material misrepresentations made by the Insured. It is understood and agreed that the statements made in

the insurance applications are incorporated into, and shall form part of, this policy. I understand that any material misrepresentation or omission

made by me on this application may act to render any contract of insurance null and without effect or provide the company the right to rescind

it.

Oklahoma Fraud Statement: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any

claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.

Oregon Fraud Statement: Notice to Oregon applicants: Any person who, with intent to defraud or knowing that he is facilitation a fraud against

an insurer, submits an application or files a claim containing a false or deceptive statement may be guilty of insurance fraud.

Pennsylvania Fraud Statement: Any person who knowingly and with intent to defraud any insurance company or other person files an

application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information

concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil

penalties.

Tennessee and Virginia Fraud Statement: 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.

Utah Notice: I understand that Punitive Damages are not insurable in the state of Utah. There will be no coverage afforded for

Punitive Damages for any Claim brought in the State of Utah. Any coverage for Punitive Damages will only apply if a Claim is filed

in a state which allows punitive or exemplary damages to be insurable. This may apply if a Claim is brought in another state by a

subsidiary or additional location(s) of the Named Insured, outside the state of Utah, for which coverage is sought under the same

policy.

Vermont Fraud Statement: 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 may be subject to fines and confinement in prison.

Virginia Notice: This Policy is written on a claims-made basis. Please read the policy carefully to understand your coverage. You

have an option to purchase a separate limit of liability for the extended reporting period. If you do not elect this option, the limit of

liability for the extended reporting period shall be part of the and not in addition to limit specified in the declarations. If you have

any questions regarding the cost of an extended reporting period, please contact your insurance company or your insurance agent.

Statements in the application shall be deemed the insured’s representations. A statement made in the application or in any affidavit

made before or after a loss under the policy will not be deemed material or invalidate coverage unless it is clearly proven that such

statement was material to the risk when assumed and was untrue.

Virginia Fraud Statement: Any person who knowingly and with intent to defraud an insurer, submits an Application for insurance or

files a claim containing a false or deceptive statement is guilty of insurance fraud.

Utah Fraud Statement: Any person who, with intent to defraud or knowing that he 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.

Washington Fraud Statement: Any person, who, knowing it to be such:

(1) Presents, or causes to be presented, a false or fraudulent claim or any proof in support of such a claim, for the payment

of a Loss under a contract of insurance; or

(2) Prepares, makes, or subscribes any false or fraudulent account, certificate, affidavit, or proof of Loss, or other document

or writing, with intent that it be presented or used in support of such a claim, is guilty of a gross misdemeanor, or if such claim

is in excess of one thousand five hundred dollars, of a class C felony.

Fraud Statement (All Other States): 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.

If your state requires that we have information regarding your Authorized Retail Agent or Broker, please provide below.

Retail agency name:

_______________________________________________ License#: __________________________________

Agent’s signature: __________________________________________Main agency phone number ___________________________

(Required in New Hampshire)

Agency mailing address:

_______________________________________________________________________________________

City: _______________________________ State: _________________________ Zip: ______________________

The undersigned represents that to the best of his/her knowledge and belief the particulars and statements set forth herein are true

and agrees that those particulars and statements are material to acceptance of the risk assumed by the Company. The undersigned

further declares that any changes to the information contained in this application prior to the effective date of the insurance applied

for which may render inaccurate, untrue, or incomplete any statement made will immediately be reported in writing to the Company

and the Company may withdraw or modify any outstanding quotations and/or authorization or agreement to bind the insurance. The

Company is hereby authorized, but not required to make any investigation and inquiry in connection with the information, statements

and disclosures provided in this application. The decision of the Company not to make or to limit any investigation or inquiry shall not

be deemed a waiver of any rights by the Company and shall not stop the Company from relying on any statement in this application.

The signing of this application does not bind the undersigned to purchase the insurance, nor does the review of this application bind

the Company to issue a policy. It is understood the Company is relying on this application in the event the Policy is issued. It is agreed

that this Application, including any material submitted there with, shall be the basis of the contract should a policy be issued and it will

be attached and become a part of the policy.

New York Fraud Statement: Any person who knowingly and with intent to defraud any insurance company or other person files an

application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading,

information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and shall also be subject to a

civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.

Signature:

__________________________________________________________________________________________________

(Chairperson of the Board, Managing Member, President or Executive Director)

Title:

_______________________________________________________Date: __________________________________________

AH APP 8/12 - USLI

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