Fillable Ambulance Supplemental Application (Risk Placement Services, Inc.)

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Ambulance Supplemental Application (Risk Placement Services, Inc.)

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CA-APP-3 (11-07) Page 1 of 4
Ambulance Supplemental Application
(Complete in addition to the Commercial Automobile Application)
1-800-423-7675 • Fax (480) 483-6752
PROVIDE COPIES OF DRIVER TRAINING MANUAL AND SAFETY PROCEDURES
Applicant’s Name:
1. Description of operations:
Number of years in business:
Number of years under current management:
2. Is your service a subsidiary or division of another company? ............................................................ Yes No
If yes, advise the name of the company, their address and their relationship to you:
3. Has this service ever operated under another name?...........................................................................
Yes No
If yes, what name?
4. Profit Nonprofit—Source of funding:
5. Do your employees work more than one shift per day? ....................................................................... Yes No
If yes, provide shift details:
6. Number of trips per year:
Number of emergency: Number of non-emergency:
Percentage of wheelchair transport:................ % Percentage of stretcher transport: ................... %
7. Is transportation provided to non-medical destinations?.....................................................................
Yes No
Daycare Centers ..........
% Heliport or Airport.............. % Psychiatric Centers.............. %
Schools ........................
% Shopping Centers ............ % Workplaces ......................... %
Senior Centers .............
% Other................................. % Describe:
8. A. List major cities entered:
B. What percentage of the operations involves transportation in these cities? ....................................
%
9. Number of units equipped with lights and sirens?
10. Who dispatches your calls? 911 Outside sources In-house by your own employees or volunteers
National Casualty Company
Scottsdale Surplus Lines
Insurance Company
Home Office: Scottsdale, Arizona
Adm. Office:
8877 Gainey Center Drive
Scottsdale, Arizona 85258
Scottsdale Insurance Company
Scottsdale Indemnity Company
Home Office: One Nationwide Plaza
Columbus, Ohio 43215
Adm. Office: 8877 North Gainey Center Drive
CA-APP-3 (11-07) Page 2 of 4
11. Do you distribute any medical supplies or equipment?........................................................................ Yes No
If yes, provide details:
12. Indicate level of training and number of individuals who drive and/or provide client care (full-time, part-time or
volunteer):
EMT BASIC
EMT
ADVANCED
EMT
PARAMEDIC
OTHER
NO
CERTIFICATION
NUMBER OF
EMPLOYEES
NUMBER OF
VOLUNTEERS
If “other” marked above, explain:
13. Identify the types of special driver training programs that your drivers receive:
General driver orientation Defensive driving Primary first aid
Advanced first aid CPR Passenger assistance training
Human relations skills Nonmedical emergency training Emergency vehicle evacuation
Emergency vehicle operators course (EVOC)
14. Do you:
Screen employees and drivers’ histories for sexual abuse charges and convictions? ...............................
Yes No
Verify licenses/professional certificates?.....................................................................................................
Yes No
Screen employees for previous involvement as defendants in malpractice litigation? ...............................
Yes No
15. How many vehicles are equipped with the following wheelchair tie-down mechanism?
3 point tie-down
4 point tie-down
16. Are any vehicles not equipped with both lap belts and shoulder harnesses for the passengers? Yes No
17. Describe wheelchair and stretcher tie-down procedures:
18. Is there an accident review procedure?..................................................................................................
Yes No
If yes, describe:
19. Describe vehicle maintenance program:
20. Does Applicant carry Professional Liability coverage? ........................................................................
Yes No
Policy Number Carrier Limits Term
Is Loading
& Unloading
Included?
Yes No
21. Does Applicant carry General Liability coverage? ................................................................................ Yes No
Policy Number Carrier Limits Term
CA-APP-3 (11-07) Page 3 of 4
22. Are all vehicles owned by you? ............................................................................................................... Yes No
If no, explain:
Are they leased, etc.?.................................................................................................................................. Yes No
Give details:
23. Do any employees/volunteers use their own vehicles in your business? ..........................................
Yes No
If yes, explain:
Are any employees/volunteers’ vehicles used for client transport? ............................................................
Yes No
24. Are all employees covered by Worker’s Compensation? ..................................................................... Yes No
If yes, provide carrier name:
25. Any other pertinent information about your business:
This application does not bind YOU or US to complete the insurance, but it is agreed that the information contained herein
shall be the basis of the contract should a policy be issued.
FRAUD WARNING:
Any person who knowingly and with intent to defraud any insurance company or other person files an application for in-
surance or statement of claim containing any materially false information or conceals for the purpose of misleading, infor-
mation concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such
person to criminal and civil penalties.
FRAUD WARNING (APPLICABLE IN FLORIDA):
Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an appli-
cation containing any false, incomplete, or misleading information is guilty of a felony of the third degree.
FRAUD WARNING (APPLICABLE IN MAINE):
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.
FRAUD WARNING (APPLICABLE IN TENNESSEE AND WASHINGTON):
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.
CA-APP-3 (11-07) Page 4 of 4
FRAUD WARNING APPLICABLE IN THE STATE OF NEW YORK:
Any person who knowingly and with intent to defraud any insurance company or other person files an application for
commercial insurance or a statement of claim for any commercial or personal insurance benefits containing any materially
false information, or conceals for the purpose of misleading, information concerning any fact material thereto, and any
person who, in connection with such application or claim, knowingly makes or knowingly assists, abets, solicits or con-
spires with another to make a false report of the theft, destruction, damage or conversion of any motor vehicle to a law
enforcement agency, the department of motor vehicles or an insurance company, 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 value of the sub-
ject motor vehicle or stated claim for each violation.
APPLICANT’S NAME AND TITLE:
APPLICANT’S SIGNATURE: DATE:
(Must be signed by an active owner, partner or executive officer.)
PRODUCER’S SIGNATURE: DATE:
AGENT NAME:
AGENT LICENSE NUMBER:
(Applicable to Florida Agents Only)
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Ambulance Supplemental Application (Risk Placement Services, Inc.)

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Completed 30 July 2020

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