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AlliedHealthApplication - ColSpec_AM - General App_11.1.10

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A
I.
1
2
3
4
5
7
9
1
1
2
1
1
4
1
1
II
.
T
h
1
M-GEN.APP
APPLICA
N
. Desired E
f
. Applicant
N
. Mailing A
d
. City, Stat
. County:
. Inspection
. Date Esta
b
1. Type of E
n
2. Enterprise
3. Estimated
4
. Estimated
5. Type of O
p
Prison/
J
Alcoho
l
Indepe
n
Other (
d
6. Full descri
.
CURREN
h
is section m
. a. Has
A
b. If Yes,
Name of Ca
A
N
T
INFORM
A
f
fective Date:
N
ame:
d
dress:
e
, Zip:
Contact:
b
lished:
n
terprise:
is:
receipts/ope
r
payroll for th
e
p
eration:
J
ail
l
/Drug Detox.
n
dent Living
(
d
escribe):
ption of servi
c
T
INSURA
N
ust be compl
e
pplicant had
p
complete th
e
rrier Effe
c
D
a
LLIED M
E
A
TION
Corporation
Municipality
Other (descr
i
For Profit
r
ating budget
e
next twelve
Mental
H
Boot Ca
m
Alcohol/
D
(
Elderly)
c
es rendered
N
CE
e
ted for prior
p
revious insu
e
following fo
r
c
tive
a
te
Expir
a
Da
t
P
a
E
DICAL
G
10
Indivi
d
In-Pa
i
be):
Not
F
for the next t
w
(12) months
:
H
ealth Inpatie
n
m
p
D
rug Inpatien
t
:
acts conside
r
rance for this
r
prior three (
3
a
tion
t
e
Li
m
a
ge 1 of 5
G
ENERA
L
6. T
e
8.
W
. Years in Bu
d
ual
tient -Psychi
a
F
or Profit
w
elve (12) m
:
n
t Grou
Lock
-
t
Apar
t
Assi
s
r
ation. Attac
h
enterprise?
3
) years of g
e
m
it Dedu
c
L APPLI
C
e
lephone Nu
m
W
ebsite Addr
e
siness Unde
r
Partnership
a
tric
onths:
p Home (No
n
-
down Facilit
y
t
ments
s
ted Living F
a
h
a copy of e
x
e
neral/profes
s
c
tible Pre
m
C
ATION
mber:
e
ss:
r
Current Ma
n
Join
t
n
-Elderly)
y
She
l
Fos
t
a
cility
x
piring policy
s
ional liability
m
ium Clai
m
(
C
Occ
n
agem ent:
t
Venture
l
ters/Halfway
t
er Care (chil
d
declarations
Y
e
coverage:
m
s Made
C
M) or
urrence?
R
11.1.10
House
d
ren)
page.
e
s No
CM
etroactive
Date
A
II
I
1
.
2
.
M-GEN.APP
I
. CLAIMS
A
. Claims an
d
Importan
t
excluded
f
any claim,
and/or su
b
a. Claim
s
insure
Dat
e
b. Incid
e
place
been
r
D
e
In
j
In
c
In
c
In
j
I
m
D
e
1) A
r
cl
a
2) H
a
re
p
. Risk Man
a
a. Are t
h
report
?
b. Who i
s
insure
Name
:
A
CTIVITY
A
d
Incident Ac
t
t
Notice: All
f
rom coverag
or incident
t
b
ject to rescis
s
s
Activity - P
r
during the
p
e
of Loss
C
e
nt Activity -
P
at any of yo
u
r
eported to a
n
e
ath of a clie
n
j
ury to a clien
c
ident involvi
n
c
ident that g
e
j
ury resulting
m
proper medi
c
e
cubitus ulce
r
r
e there any
o
a
im against t
h
a
ve all known
p
orted to you
a
gement Prot
o
h
ere procedu
r
?
s
responsible
r
?
:
A
ND INCID
E
t
ivity
known claim
e. Report al
t
hat could re
a
s
ion.
lease list all
ast five year
s
C
urrent Res
e
Paid Am
o
P
lease outlin
e
u
r facilities f
o
n
y insurer:
n
t, patient or
r
t
, patient or r
e
n
g abuse, m
o
e
nerated a for
m
from an elop
e
c
ation or imp
r
r
(s) first acqu
i
o
ther known i
n
h
e Applicant?
incidents th
a
r
current or p
r
o
cols
r
es in place
for receiving
P
a
NT REPO
R
s and/or inc
i
l such claim
s
a
sonably res
u
claims that
h
s
. Please co
n
e
rve or
o
unt
e
the details
o
r which cov
e
r
esident from
e
sident that r
e
o
lestation, se
x
m
al complai
n
e
ment or una
r
oper dosage
i
red under yo
u
n
cidents that
a
t could reas
o
r
ior insurer?
requiring the
and recordin
a
ge 2 of 5
TING
PRO
C
i
dents that c
o
s
or incident
s
u
lt in a claim,
h
ave been p
r
n
tinue on a s
e
Descri
p
below regard
e
rage is bei
n
other than n
a
e
quired hosp
i
x
ual assault,
r
n
t or notice fr
o
uthorized ab
s
resulting in h
u
r care that h
could reason
o
nably be ex
p
documentati
g information
C
EDURES
o
uld reason
a
s
to your cur
r
,
may result
i
r
esented to
y
e
parate sheet
p
tion of Los
s
d
ing any of t
h
n
g requested
,
a
tural causes
;
i
talization;
r
ape or impro
o
m any feder
a
s
ence of a cli
e
ospitalization
h
ave reached
ably be expe
p
ected to res
u
on of all inci
d
n
relating to in
Title:
a
bly result in
r
ent insurer.
i
n the propo
s
y
ou or to yo
u
of paper if n
e
s
h
e following i
n
, but where
;
per contact;
a
l or state reg
e
nt, patient o
r
; or
Stage IV.
cted to resul
t
u
lt in a claim
b
d
ents in a w
r
n
cidents and
r
a claim are
Your failure
s
ed insuranc
e
u
r past or y
o
e
cessary.
Ins
u
n
cidents that
such inciden
t
ulatory body;
r
resident;
t
in a
Y
b
een
Y
r
itten
Y
r
eporting the
m
11.1.10
specifically
to disclose
e
being void
o
ur current
u
rer
have taken
t
s have not
Y
es No
Y
es No
Y
es No
m
to your
AM-GEN.APP Page 3 of 5 11.1.10
3. Other
a. Has any license or accreditation ever been suspended, denied or revoked? Yes No
b. Please list all professional association(s) in which the Applicant is a member in good standing:
c. Has the Applicant ever had its professional liability insurance policy cancelled or non -
renewed? Yes No
d. If Yes, please explain:
IV.
OPERATIONS
1. Indicate current staffing levels:
Staff
Employed Contracted
Full Time Part Time Full Time Part Time
Administrators

MD/Physicians

Nurses

Homemakers/Nurse Aids

Psychologists

Counselors

Therapists

Students or volunteers

Other (describe):

2. Check the hiring procedures that apply or are performed by this operation:
Criminal Background Checks Verification of certification or professional licensing
Drug screening or testing Reference Checks
Questioning of employees in their previous involvement as defendants in professional malpractice litigation
3. Schedule of Physicians – on Staff or Contracted:
Name & Specialty
Board
Certified
Board
Eligible
Hours/Week
Worked
Volunteer, Contracted
or Employed
Has
Malpractice
Insurance

Yes No

Yes No

Yes No

Yes No
4. List the duties of the physician(s) in 3. above:
5. Do you want any listed physician to be covered under the facility’s policy? Yes No
6. a. Are any drugs or medications administered or prescribed? Yes No
b. If Yes, please explain:
AM-GEN.APP Page 4 of 5 11.1.10
V. LOCATION
INFORMATION
1. Schedule of Locations: If more than five locations, please attach a separate sheet of locations.
Address Types of Services Provided
# 1

# 2

# 3

# 4

# 5

2. a. Are there any camp, adventure/wilderness, ropes courses or any type of recreational
programs? Yes No
b. If Yes, please submit brochure or describe activities:
3. a. Are there any firearms on the premises? Yes No
b. If Yes, please describe:
c. Are the firearms locked in a secure place away from the residents? Yes No
d. If No, please describe:
4. a. Are there any animal exposures on the premises? Yes No
b. If Yes, are the animal exposures: Owned Non-owned?
c. If Yes, please describe, including number of animals and type/breed:
5. a. Are there any lakes, ponds, rivers, pools or other bodies of water on the premises? Yes No
b. If Yes, please describe:
c. Are there any swimming or boating activities? Yes No
d.
e.
If there is a pool or body of water, then is it fenced with a self-locking gate?
If there is a pool or body of water, then is there a diving board and/or slide?
Yes
Yes
No
No
VI. COVERAGE
REQUESTED
1. Complete and attach the appropriate supplemental application with your submission.
2. Check the coverages and limits that the Applicant would like quoted:
a. Coverages: GL Professional Excess (Attach Acord App)
b. Limits: $100,000/$100,000 $300,000/$300,000 $500,000/$500,000
$1,000,000/$1,000,000 $1,000,000/$2,000,000 $1,000,000/$3,000,000
3. a. Do you want physical abuse/sexual molestation coverage to protect you for alleged acts
of your employees?
Yes No
b. If Yes, at what limits? $25,000/$50,000 $50,000/$100,000 $100,000/$300,000
$250,000/$250,000 $500,000/$500,000 Other:
A
P
o
w
*
f
o
m
m
*
W
T
r
e
o
f
i
s
i
m
a
u
p
A
T
S
c
u
M-GEN.APP
lease attach
Five (5) y
e
w
ner/director
)
Brochure(
s
Any person
w
o
r insurance
m
isleading, in
f
m
ay be subje
c
Not applicabl
W
ARRANTY
he undersig
e
sult of said
f
ficer agree
s
s
signed an
d
m
mediately
n
u
thorization
urchase, or
u
A
uthorized Si
g
T
itle/Date
IGNING THI
S
u
rrently sig
n
a copy of t
h
e
ars of curre
n
)
s
) available o
r
w
ho knowing
l
or statemen
t
f
ormation co
n
c
t to a civil pe
n
e in all state
s
STATEME
N
ned authori
z
officer’s in
q
s
that if the
i
d
the effecti
v
n
otify us of
s
or agreeme
u
s to issue,
a
g
nature on beh
a
S
FORM DO
E
n
ed, complet
e
h
e following
w
n
tly dated los
s
r
other inform
l
y and with i
n
t
of claim c
o
n
cerning any
n
alty or fine.
s
N
T AND
SI
G
z
ed officer
o
q
uiry and, a
s
i
nformation
v
e date of t
s
uch chang
e
nt to bind t
h
a
ny insuran
c
a
lf of Applican
t
E
S NOT BIN
D
e
d and date
d
P
a
w
ith your su
b
s
runs (if in b
u
ation pertaini
n
tent to defra
u
o
ntaining an
y
fact materia
l
G
NATURE:
o
f the Appli
c
s
such, are
t
supplied on
he insuranc
e
s and we
m
h
e insuranc
e
c
e policy.
t
D
THE COM
P
d
to be cons
i
a
ge 5 of 5
b
mission:
u
siness less
t
ng to the pro
g
u
d any insur
a
materially f
a
l
thereto, ma
c
ant declare
s
t
rue, accura
t
the applica
t
e that is th
e
m
ay withdra
w
e
. Signing t
h
S
P
P
ANY TO IS
S
i
dered for q
u
t
han five (5)
y
g
rams offere
d
a
nce compan
a
lse informat
a
y be commi
t
s that the s
t
t
e and com
p
t
ion change
s
e
subject o
f
w
or modify
a
h
is applicati
S
ub-Producer
P
roducer
S
UE THIS IN
S
u
otation.
y
ears, please
d
n
y or other p
e
ion, or conc
e
t
ting a fraud
u
t
atements s
e
p
lete. The u
s
between t
h
f
this applic
a
ny outstan
d
on does no
t
S
URANCE.
A
attach a res
u
e
rson files an
e
als for the
u
lent insuran
c
e
t forth her
e
ndersigned
h
e date the
a
a
tion, such
d
ing quotati
o
t
bind the A
p
Application
11.1.10
u
me of the
application
purpose of
c
e act, and
e
in are the
authorized
a
pplication
officer will
o
ns and/or
p
plicant to
MUST be
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Completed 2 July 2020

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