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Allied Healthcare Professional and General Liability Product (Access E&S Insurance Services)

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Allied Healthcare Professional and General Liability
Product
AH APP 7/12 - 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: _________________________________________________________________________ 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? Yes 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? Yes No Not applicable
If “No,” explain _________________________________________________________________________________________________________
3. Has any professional(s) seeking coverage been providing their services less than three years? Yes 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. Yes No 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? Yes No
If “Yes,” please provide details ______________________________________________________________________________________________
7. Does the applicant have any subsidiaries for which coverage is sought? Yes 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
1.
2.
3.
4.
5.
6.
Access E&S Insurance Services Inc.
www.access-es.com
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? Yes No
b) Injections of any kind? Yes No
c) Diagnosing conditions, disorders or diseases in patients? Yes No
d) Services as a physician, surgeon, nurse, anesthetist, anesthesiologist, psychiatrist, chiropractor,
acupuncturist, pharmacist or dentist? Yes No
e) Overnight services? Yes No
f) Designing, testing, selling, distributing or manufacturing products of any kind including vitamins, minerals, herbal,
medicinal or nutritional supplements? Yes No
g) More than twenty five percent of services involving the transportation of clients/patients? Yes No
h) Prescribing, monitoring or dispensing medication, equipment, or devices? Yes No
i) Provide professional services within any prison/correctional facility or for any probation or prison release program? Yes No
j) Hospice care? Yes No
k) Medical healthcare services (including but not limited to monitoring blood pressure, changing dressings, Yes No
monitoring respiration rates)?
l) Provide more than ten percent of services within a nursing home(s), or hospital? Yes 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? Yes No
10. Does the applicant obtain a written informed consent from parents/guardians of minors
receiving services? In all cases Sometimes 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? Yes No
(b) Are any such actions pending as of the date of this application? Yes No
13. Has the applicant initiated litigation against any patients or clients in the past five years? Yes 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? Yes 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? Yes No
16. Has any policy of professional liability insurance ever been cancelled or non-renewed by an insurance carrier? Yes No
(Not applicable in Missouri) If “Yes,” provide details__________________________________________________
17. (a) Does the applicant currently have professional liability insurance in force? Yes No
(b) Does the applicant currently have general liability insurance in force? Yes 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? Yes No 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? Yes No
If “Yes,” please provide details. ____________________________________________________________________
2. Additional insured(s) to be included for general liability coverage:
AH APP 7/12 - USLI
page 2 of 5
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? Yes No (Not applicable in Missouri)
If “Yes,” provide details___________________________________________________________________________
4. Is the applicant the owner of the insured location? Yes 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: Frame Joisted masonry Non-combustible Masonry non-combustible
Modified fire-resistive Fire-resistive Other ___________________
2. Protection class: ___________________
3. Requested cause of loss: Basic Special
4. Requested valuation: Replacement cost Actual cash value
5. Deductible: $1,000 $2,500 $5,000
6. Coinsurance: 80% 90% 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? Yes No
13. Age of roof ________yrs.
14. Roof type: Flat Wood shake Shingle Metal Tile Slate Other _____________________
15. What Protection devices do you have on the premises? Burglar Alarm Fire Alarm Central station Local
16. Do you have Functional & Operating Smoke detectors? Yes No
17. List your loss information for the past three years:
Property Coverages None, or provide detail below:
Year Status Incurred Description
_______ Open/Closed $ ______________ _____________________________________________________________________________
_______ Open/Closed $ ______________ _____________________________________________________________________________
_______ Open/Closed $ ______________ _____________________________________________________________________________
18. Has your Insurance coverage been cancelled or non-renewed within the last three years? (not applicable in MO) Yes No
19. Have you gone bankrupt within the past three years? Yes No
20. For any building built prior to 1978, do any lack knob-and-tube or aluminum wiring on premises? Yes No
21. For any building built prior to 1978, is 100% of the wiring on functioning and operational circuit breakers Yes 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? Yes No
2. Does organization own any motor vehicles or lease any motor vehicles on a long term basis (greater than 30 days)? Yes No
3. Does organization use hired or non-owned vehicles with passenger capacities exceeding 15 passengers? Yes No
4. Does organization use hired or non-owned vehicles for emergency medical transportation or emergency medical services? Yes No
5. Does organization transport non-ambulatory persons? Yes No
6. Does organization require evidence of insurance from employees, independent contractors and volunteers? Yes 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? Yes No
8. Number of drivers: __________
9. Average driving frequency per week by drivers: Once 2-3 times 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 2/12 - USLI
page 3 of 5
AH APP 7/12 - USLI
page 4 of 5
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) Y ou 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 7/12 - USLI
page 5 of 5
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Allied Healthcare Professional and General Liability Product (Access E&S Insurance Services)

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Completed 8 January 2021

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