Fillable Application - Adult Day Care Supplemental36-12813

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Application - Adult Day Care Supplemental36-12813

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ADULT DAY CARE PROGRAM SUPPLEMENTAL
Named Insured:
Location Address:
E-mail:
Web Address:
Risk Management Contact:
Risk Management’s Phone:
Risk Management Email:
REQUIREMENTS FOR SUBMISSION
• Completed and signed/dated PHLY Adult Day Care Supplemental Application
• Completed ACORD Application
• Copy of current Adult Day Care license(s)
• Brochures, pamphlets and/or other advertising materials
• Currently valued insurance company loss runs for the current policy period plus three prior years
SECTION I – GENERAL APPLICATION INFORMATION
.
1.
This adult day care center is located in which type of building?
Commercial
Church
School
Other (describe):
Private Home (NOT Eligible)
2.
The neighborhood is primarily:
Commercial / Industry
Residential
Urban / City
Country / Farming
3.
Hours of operation:
4.
Any overnight stays?
Yes
No
5.
Number of successful years in business under the same management:
6.
Indicate if a file containing the following information is maintained on each client:
a.
Are there records for each client indicating unusual conditions the client has?
Yes
No
b.
Are signed releases for emergency medical treatment/dispensing of medication obtained from
guardians?
Yes
No
c.
Are written instructions from client’s physicians for dispensing of client’s medication?
Yes
No
7.
Is food properly covered, stored and served in accordance with applicable government
requirements?
Yes
No
Licensing:
1.
Is the adult day care center licensed?
Yes
No
If yes: License #:
Expiration date of license:
License Capacity:
2.
If licensing is NOT state required, why is it exempt?
3.
Has a license to operate ever been denied, suspended or revoked?
Yes
No
If yes, attach a separate full explanation.
4.
Does Applicant provide transportation?
Yes
No
5.
Has the Applicant ever received any citations or warnings issued by any state or governmental
entity?
Yes
No
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Type of Day Care:
# of Total
Clients
Served
% of
services
Type I:
Adult day social care provides social care and social activities such as meals,
recreation and some basic health-related services such as having a nurse on staff
to check pressure (Light exposures).
%
Type II:
Adult day health care offers more intensive health, therapeutic, and social services
for individuals with moderate to severe medical and cognitive problems including
an incidental exposure (up to 25%) of clients with Alzheimer’s. Activities within
this category also include social activities for clients that require more intense
health, therapeutic and medical care. (Moderate to heavy exposures)
%
Type III:
Alzheimer’s specific adult day care provides social and health services to persons
with Alzheimer’s or related dementia. The predominant exposure in this category
are clients with this diagnosis or organizations that have an Alzheimer’s or related
dementia exposure greater than an incidental as outlined within the Type II
description.
%
For Type II and III, please outline the types of medical services provided:
SECTION II – MANAGEMENT PRACTICES
1.
Does Applicant have sign in / out procedures for:
Staff?
Yes
No
Clients/Residents?
Yes
No
Visitors/Public?
Yes
No
2.
Type of security provided for the protection of your clients / residents?
Guards
Video Cameras
Other:
3.
What measures are taken to monitor client activities?
4.
Describe the procedures currently in place, which prevents the clients from wondering off or
outside the premises?
5.
What precautions do you take to prevent non-staff members from accessing unauthorized areas of
the property?
6.
Do you have incident reporting procedures and / or committee reviews?
Yes
No
7.
Do you have a plan for medical emergencies?
Yes
No
8.
Is there always someone trained in CPR and first aid on the premises?
Yes
No
9.
Do you have Automatic External Defibrillator(s)?
Yes
No
10.
Are staff members trained to use it?
Yes
No
11.
Do you have a written and enforced no smoking policy?
Yes
No
12.
Are “no smoking” signs posted in all areas not designated from smoking?
Yes
No
SECTION III – PROFESSIONAL LIABILITY
1.
Does the Applicant require their staff (paid & volunteer) to complete an employment application?
Yes
No
If no, please explain:
2.
Does the Applicant conduct a personal interview for each prospective staff member?
Yes
No
3.
Does the Applicant verify employment related references?
Yes
No
4.
Does the Applicant verify licenses and other credentials?
Yes
No
5.
What action does the Applicant take if any report is considered unfavorable?
6.
Does the Applicant share written job descriptions with all staff members?
Yes
No
7.
Name of executive director / manager:
Number of years experience in this field:
Number of years at this facility:
Specialized training or education:
8.
What is the staff turnover rate for the last twelve (12) months?
9.
Does the Applicant provide workers compensation for:
All staff members
Workshop Employees
Contractors
Consultants
10.
Is the staff required to report to the administrator all incidences that may result in a claim?
Yes
No
If yes, is a written report kept?
Yes
No
Are they reviewed?
Yes
No
11.
Are clients referred to specialists when appropriate?
Yes
No
12.
Are files maintained to protect confidentiality of clients?
Yes
No
13.
Does the Applicant do any consulting work?
Yes
No
If yes, please explain:
Adult Day Care Supplemental
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14.
Does the Applicant’s current insurance program provide professional liability coverage?
Yes
No
If yes:
Occurrence
Claims Made – Retroactive date:
Limits: $
Carrier:
Effective dates:
15.
Physicians and Psychiatrists
Name:
Dr.
Dr.
Dr.
Specialty:
Board certified or eligible:
Years in practice:
License Number:
Hours per week for Applicant:
Employed or Contracted?
Does each individual carry his / her own
malpractice insurance?
Yes
No
Yes
No
Yes
No
If yes, does coverage include acts while
working for center?
Yes
No
Yes
No
Yes
No
If yes, does coverage include contingent
coverage for center?
Yes
No
Yes
No
Yes
No
Any claims past five (5) years?
Yes
No
Yes
No
Yes
No
16. Annual Staffing – Employees, Independent Contractors and Volunteers
Total number of: Full Time Employees: Part Time Employees: Volunteers:
Staffing
# of Employees # of Contracted
Total Annual Volunteer
Hours Worked
FT PT FT PT
Psychologist
Medical Director (Admin Only)
Nurse Practitioner
Physician Assistant
Pharmacist
Paramedic EMT
Psychiatrist
Physician-Hospice
Pediatrician
Physician-No Surgery
Dentist
Optometrists/Ophthalmologist
Licensed Social Worker
Sociologist
Registered Nurse (RN)
Licensed Practical Nurse (LPN)
Physical Therapist
Optician
Orthotics & Prosthetics (O&P)
Certified Practitioner
Counselor (Guidance, Vocational)
Social Worker
Occupational Therapist
Speech Therapist
Clergy / Rabbi / Pastor
O&P Certified Technician
Teacher
Nutritionist / Dietician
Residential Manager
Home Health Aide
Day Care Worker
O&P Certified Fitter
O&P Certified Assistant
Adoptions
Foster Care
*Other (describe):
*Other (describe):
F/T = Full Time – over 20 hours per week/ P/T = Part Time – up to 20 hours per week.
*Please describe “other” staff positions not listed in the above chart in the provided area.
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17.
If the Applicant is requesting primary medical professional coverage for any of above noted Physicians,
Psychiatrists, Dentists or Opticians, the Applicant must submit a completed and signed Medical
Professional application. Coverage for such professional is subject to Underwriting review and approval.
18.
If the above noted employed or volunteer Physicians, Psychiatrists, Dentists or Opticians carry their own
medical malpractice insurance, we may provide vicarious medical professional coverage for the entity as
respects to the professional services rendered on the insured’s behalf. Coverage for the entity will
require the following: The Professional’s name, medical license number, medical specialty and proof
that the professional carries adequate limits of insurance (at least $1million limit of liability). Proof of
insurance may be satisfied by submitting a copy of the professional’s declaration page and/or certificate
of insurance.
19.
Consultant / Independent Contractors
Are there written agreements with independent contractors?
Yes
No
Are certificates of malpractice / professional liability insurance obtained and maintained for all
contracted service providers (independent contractors)?
Yes
No
Please indicate the limits of liability: $
20.
Based on the maximum number of clients enrolled on your busiest day, enter the numbers of staff and clients in
each of the following categories:
TYPE OF ADULT DAY CARE
# OF CARE PROVIDERS
# OF CLIENTS
MALE
FEMALE
TYPE I
TYPE II
TYPE III
(The ratios of staff-to-client must be at least the state required ratio)
21.
Are any staff less than 18 years old?
Yes
No
(Indicate specific duties for each on a separate document.)
22.
Does the Applicant use any volunteers?
Yes
No
(Indicate specific duties for each on a separate document.)
23.
Is a minimum of one staff member certified in First Aid present at all times?
Yes
No
24.
Is a minimum of one staff member certified in CPR present at all times?
Yes
No
SECTION IV – HIRING / SCREENING
1.
Are employees screened to rule out drug, alcohol and sexual abuse?
Yes
No
2.
Check all methods used in hiring all employees or independent contractors:
Drug Testing?
Criminal Background Checks – Federal
Criminal Background Checks – State
Reference Checks
Personal Interview
Sexual Abuse Registry
Validate Driver’s License
Validate Work History
Validate Education
Verify Current Certification / Professional License
Validate Personal Auto Insurance and Limits (if operating owned vehicle during company hours)
3.
How are references checked:
Written
Verbal
Both
If verbal only, please explain:
4.
Are all of the above methods done prior to binding?
Yes
No
If no, please explain:
SECTION V – SEXUAL ABUSE
N/A
1.
Does the Applicant’s current insurance program include Abuse and Molestation Coverage?
Yes
No
If yes, Occurrence or Claims Made – Retro Date:
Limit of Liability: $
Carrier:
Effective Date:
2.
Does the Applicant’s employment process include verification of whether the individual has ever
been convicted of any crime, including sex related or child-abuse related offenses, before an offer
of employment is made?
Yes
No
3.
Does the Applicant have a written crisis plan in place for dealing with employees, victims, parents,
authorities, and the media if the Applicant has incident of abuse?
Yes
No
4.
Are there written complaint procedures and are they displayed prominently?
Yes
No
If yes, explain:
5.
Is there a written supervision plan that monitors staff in day-to-day relationships with clients, both
on and off premises?
Yes
No
6.
Are formal written procedures in place for hiring?
Yes
No
7.
Do volunteers work directly with clients?
Yes
No
8.
Is there formal staff training on child/sexual abuse, including how to recognize the signs?
Yes
No
9.
What procedures are in place to make sure no relationship occurs between staff and clients?
10.
Are there procedures prohibiting closed door one-on-one meetings / counseling?
Yes
No
11.
Is there more than one person responsible for the welfare of any single patient?
Yes
No
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12.
Have any incidents resulted in an allegation of sexual abuse?
Yes
No
Was the case settled?
Yes
No
Was the case taken to trial?
Yes
No
Amount paid for damages to the victim: $
13.
Does the Applicant run criminal background checks on employees?
Yes
No
14.
Does the Applicant run criminal background checks on volunteers?
Yes
No
SECTION VI – PREMISES / LIFE SAFETY
1.
If the building you occupy was built prior to 1971; has it been inspected for lead paint?
Yes
No
If no, what is the plan for abatement?
2.
Does the property have aluminum wiring?
Yes
No
If yes, has it been retrofitted with one of the PHLY approved connectors by a licensed Electrician?
(indicate which one): COPALUM? Yes No AlumiConn?
Yes
No
Date updated:
Please supply retrofit documentation or statement from installing contractor.
3.
Have asbestos material been:
determined not to be present
removed
or
protected to prevent flaking?
4.
Do you have any plans for renovations or new construction?
Yes
No
5.
Does the Applicant’s center exit directly to the outside?
Yes
No
To ground level?
Yes
No
6.
Are there any non-ambulatory clients?
Yes
No
If yes, how many?
Any located above the first floor?
Yes
No
7.
Please indicate which of the following fire suppression devised are currently in use and in effect:
Automatic Sprinkler System
Central Station Fire Alarm System
Smoke Detectors
Manual Pull Fire Alarms
Fire Extinguishers
Other:
8.
How many means of egress are there?
Are all exits clearly marked & illuminated?
Yes
No
9.
Are all exit doors equipped with panic hardware?
Yes
No
10.
Is there a fire escape?
Yes
No
If yes, please describe:
11.
Do you have a written emergency evacuation plan?
Yes
No
If yes, are the emergency evacuations procedures and floor plan posted?
Yes
No
Have you established a central meeting point outside the building?
Yes
No
Does the emergency plan include notification to the fire department?
Yes
No
How often are drills held?
12.
Do you have emergency lighting or backup generators in the event of a power failure?
Yes
No
13.
Do you have a formal maintenance housekeeping program in place?
Yes
No
14.
Do you own or rent a parking facility?
Yes
No
If yes, are they well lit?
Yes
No
15.
Is the hot water heater set to a temperature of 120 degrees?
Yes
No
Do you have an equipment maintenance program in place?
Yes
No
16.
Has your facility been inspected by an insurance company or independent inspection firm?
Yes
No
If yes, by whom?
On a separate sheet, please list any deficiencies and corrective actions in the past three (3) years:
17.
Does the Applicant comply with board of health regulations and with building codes?
Yes
No
18.
Are medical facilities, such as a first aid or nurse’s station located on the premise?
Yes
No
19.
Please indicate the dates of the latest updates regarding the following common hazards:
Electrical/Wiring:
Plumbing:
Heating:
Type of Heating:
Type of Roof:
Age of Roof:
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SECTION VII – CLAIMS MADE
N/A
Notice: This section is being completed as an application for a Claims-Made policy. Only claims which are first
made against the Applicant and reported to us during the policy period or Extended Reporting Period will be
cover
ed, subject to policy provisions. Various provisions in the policy restrict coverage. Read the entire
policy carefully to determine the Applicant’s rights, duties and what is and is not covered.
N/A (Please proceed to signature section)
Policy Effective Date:
Line of Business:
1.
Within the past 5 (five) years has the Applicant given written notice under the provisions of any
current or prior policy providing similar insurance of any claim or of any specific facts or
circumstances which might give rise to a claim being made against the Applicant?
Yes
No
If yes, please provide details:
2.
With respect to the coverages applied for, upon inquiry of any of person qualifying as a Named
Insured under the proposed policy, are there any facts, circumstances, or situations which might
give rise to a claim under the coverage(s) for which the Applicant is applying?
Yes
No
If yes, please provide details:
SECTION VIII - AUTOMOBILE
Owned Automobiles
1. Are all vehicles listed on the ACORD application titled to the Applicant? Yes No
If no, please explain:
2. Where does the Applicant keep their own vehicles?
Garage Driveway Parking Lot Other:
3. Are keys locked and secured away from non-drivers when not in use? Yes No
4. Are vehicles with eight or more seating capacity equipped with an audile backup warning device? Yes No
5. Does the Applicant provide transportation for:
Staff Clients / Residents Visitors / Public Meals
If yes for clients / residents, is more than one staff member required in the vehicle? Yes No
If yes for meals, what precautions do you take to prevent food spoilage?
6. Does the Applicant transport clients / residents for other human services agencies? Yes No
If yes, please explain:
7. Does the Applicant provide transportation for field trips? Yes No
If the Applicant does not provide transportation, how is it provided?
If vehicles are hired for field trips, are they hired with a driver? Yes No
8. Does the Applicant’s employees / volunteers transport clients in their own vehicles? Yes No
If yes, how often?
9. Are vehicles checked after passengers disembark to make sure no one is left behind? Yes No
10. Do vehicles equipped for wheelchairs have tie-down belts to stabilize the wheelchair and
passenger?
Yes No
11. Does the Applicant require seat belts to be worn by all occupants? Yes No
12. Does the Applicant have a vehicle maintenance program in place? Yes No
13. Does the Applicant’s organization utilize GPS fleet telematics devices? Yes No
If yes, please check off the fleet telematics being utilized:
Plug in Hard wired Mobile Phone Other:
14. What percentage of the Applicant’s fleet is provided with these fleet telematics devices? %
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Hired and Non-Owned
N/A
1.
Does the Applicant hire vehicles?
Yes
No
If yes, what type of vehicles does the Applicant hire?
Does the Applicant obtain Certificates of Insurance?
Yes
No
What minimum limits does the Applicant require? $
2.
Does the Applicant hire from a transportation company?
Yes
No
If yes, with drivers?
Yes
No
3.
Total number of hired vehicles:
Annual cost of hire: $
4.
How many drive personal vehicles for business use regularly?
F/T:
P/T:
Vol:
How many drive personal vehicles for business use occasionally?
F/T:
P/T:
Vol:
Does the Applicant obtain proof of insurance for employees / volunteers who use their own autos?
Yes No
Does the Applicant update these records at least yearly?
Yes
No
What minimum limits does Applicant require? $
Drivers
N/A
1.
Does the Applicant obtain a written authorization to release driver information from all of the
Applicants staff upon hiring?
Yes
No
Does the Applicant obtain MVRs on all drivers?
Yes
No
If yes, how often?
2.
What are the Applicant’s procedures for dealing with driver accidents or violations?
3.
Are all drivers at least twenty-one (21) years of age?
Yes
No
4.
How many drivers (employees and volunteers) aged twenty-one (21) to twenty-five (25) transport
clients in agency vehicles?
5.
Do any drivers have a Commercial Driver’s License (CDL)?
Yes
No
6.
Explain the Applicant’s driver safety program:
7.
Is training provided for new employees / volunteers prior to their transporting clients?
Yes
No
If yes, please explain:
8.
Does anyone besides employees or volunteers drive Applicant’s vehicles?
Yes
No
If yes, please explain:
9.
Does the Applicant allow personal use of the Applicant’s agency vehicles?
Yes
No
If yes, by whom and for what reasons?
SECTION IX – SWIMMING POOLS
N/A
1.
Is there a training lifeguard on duty?
Yes
No
If yes, how many? During what hours?
2.
The pool area includes:
Jacuzzi
Whirlpool
Hot Tub
Spa
Kiddie Pool
Water Slide
Trampoline
3.
Is the pool completely fences with a self-locking gate?
Yes
No
If yes, what is the height?
4.
Pool location:
Indoor
Outdoor
5.
Is there a diving board?
Yes
No
If yes, what is the height?
6.
Are depths clearly marked?
Yes
No
7.
Is life saving equipment readily accessible?
Yes
No
8.
Is walking surface around the pool non-skid and in good condition?
Yes
No
9.
Is the staff trained in water safety?
Yes
No
10.
Are all areas of the pool, including the bottom, visible at all times?
Yes
No
11.
Are “swim at your own risk” signs posted with pool rules?
Yes
No
Do the posted rules meet state and local regulations?
Yes
No
12.
Is the storage of pool chemicals secured?
Yes
No
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13.
How often is the pool cleaned?
14.
Do you have specific guidelines regarding closing the pool due to water contamination?
Yes
No
15.
Are all swimming pools and spas complaint with the Virginia Graeme Baker Pool and Spa safety
act?
Yes
No
If no, provide time table and action plan:
SECTION X – FIELDTRIPS / OFF PREMISES TRAVEL
N/A
1.
Are field trips taken (or do you anticipate field trips during the next 12 months)?
Yes
No
If yes, answer the following:
2.
Describe the field trips:
3.
Does the Applicant travel off premises for other events such as fundraising events?
Yes
No
4.
Describe those trips:
SECTION XI – SPECIAL EVENTS
N/A
1.
Are any pets or animals kept on premises?
Yes
No
Describe animals, caging, and type of interaction:
2.
Are special classes provided? (Exercise, Dance, etc.)
Yes
No
If yes, please explain:
3.
Are special classes taught by an independent contractor on your premises?
Yes
No
4.
Does Applicant request / maintain Certificates of Insurance from all sub-contractors?
Yes
No
5.
Does the Applicant have any operations other than Adult Day Care?
If yes, please explain:
SECTION XII – KITCHEN EXPOSURE
N/A
1.
Is cooking permitted on the premises?
Yes
No
2.
Is the actual cooking of food prepared and cooked by the staff?
Yes
No
3.
Are there fire extinguishers in the cooking area available?
Yes
No
4.
The cooking equipment is:
Residential
Commercial
5.
Cooking equipment is equipped with:
Nothing
Hoods
Ducts
Exhaust Fans
Automatic Fire Suppression System
Automatic Fuel shut off control
6.
How often is the cooking equipment cleaned?
Is the cleaning equipment:
Cleaned by you
Cleaning Contractor
Yes No
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WINTER WEATHER FREEZE-UP PROTECTION
1. Fire Protection and Testing
a. Is the building provided with an Automatic Fire Sprinkler System (AS)? Yes No N/A
i. If yes, approximately what percentage (%) of the building is sprinklered? %
ii. If yes, what type of sprinkler system is installed? Wet-Pipe Dry-Pipe Both
iii. If yes, when possible, is the sprinkler piping primarily run within conditioned
areas designed to ensure the temperature remains above the 45°F minimum
Yes No N/A
iv. If yes, is the testing & inspection by qualified sprinkler contractor completed
within past 12 months & includes a formal winterization re
view?
Yes
No
N/A
v. If yes, are the alarms tied to a 24 hour UL listed monitoring company?
Yes
No
N/A
2. Emergency Water Response (domestic and AS water lines)
a. Are water shutoff valves (domestic and AS water lines) marked and readily
accessible?
Yes
No
N/A
b. Are water shutoff valves exercised (closed and reopened) at least annually?
Yes
No
N/A
c. Is the staff qualified to respond and shut off the water main during normal business
hours and off hours?
Yes
No
N/A
3. Automatic Water Shutoff Devices
a. For domestic water lines, is there a water flow detection, notification and automatic
shutoff?
Yes
No
N/A
4. Unused/Vacant Spaces
a. Does Applicant have a formal process to turn off and drain domestic water lines for
these spaces?
Yes
No
N/A
5. Unheated Areas (attics, crawl spaces, exterior wall joists)
a. Are all domestic water lines located in areas heated to at least 45°F?
Yes
No
N/A
i. If no, please describe freeze prevention measures (e.g. temperature monitoring,
heat trace, full insulation):
This section must be completed by all risks that have a location in one of the following states: AR, CT, DC, DE,
GA, IL, IN, KY, ME, MD, MA, MI, MO, NH, NY, NJ, NC, OH, PA, RI, SC, TN, TX, VT, VA, WV, WI
temperature?
1. If no, please describe freeze prevention measures (
e.g. temperature
monitor
ing, heat trace, full insulation on piping or roof):
6.
General Comments:
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FRAUD STATEMENT AND SIGNATURE SECTIONS
The Undersigned states that he/she is an authorized representative of the Applicant and declares to the best of his/her knowledge and belief
and after reasonable inquiry, that the statements set forth in this Application (and any attachments submitted with this Application) are true
and complete and may be relied upon by Company * in quoting and issuing the policy. If any of the information in this Application changes
prior to the effective date of the policy, the Applicant will notify the Company of such changes and the Company may modify or withdraw the
quote or binder.
The signing of this Application does not bind the Company to offer, or the Applicant to purchase the policy.
*Company refers collectively to Philadelphia Indemnity Insurance Company and Tokio Marine Specialty Insurance Company
VIRGINIA APPLICANT: READ YOUR POLICY. THE POLICY OF INSURANCE FOR WHICH THIS APPLICATION IS BEING MADE, IF ISSUED,
MAY BE CANCELLED WITHOUT CAUSE AT THE OPTION OF THE INSURER AT ANY TIME IN THE FIRST 60 DAYS DURING WHICH IT IS IN
EFFECT AND AT ANY TIME THEREAFTER FOR REASONS STATED IN THE POLICY.
FRAUD NOTICE STATEMENTS
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 AND SUBJECTS THAT PERSON TO
CRIMINAL AND CIVIL PENALTIES (IN OREGON, THE AFOREMENTIONED ACTIONS MAY CONSTITUTE A FRAUDULENT INSURANCE ACT WHICH MAY
BE A CRIME AND MAY SUBJECT THE PERSON TO PENALTIES). (IN NEW YORK, THE CIVIL PENALTY IS NOT TO EXCEED FIVE THOUSAND DOLLARS
($5,000) AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION). (NOT APPLICABLE IN AL, AR, AZ, CO, DC, FL, KS, LA, ME, MD, MN,
NM, OK, PA, RI, TN, VA, VT, WA AND WV).
APPLICABLE IN AL, AR, AZ, DC, LA, MD, NM, RI AND WV: ANY PERSON WHO KNOWINGLY (OR WILLFULLY IN MD) PRESENTS A FALSE OR
FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR WHO KNOWINGLY (OR WILLFULLY IN MD) PRESENTS FALSE INFORMATION IN AN
APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES OR CONFINEMENT IN PRISON.
APPLICABLE IN COLORADO: 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 REGULATORY
AGENCIES.
APPLICABLE IN FLORIDA AND OKLAHOMA: 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 (IN FL, A PERSON IS GUILTY OF A FELONY OF THE THIRD DEGREE).
APPLICABLE IN KANSAS: AN ACT COMMITTED BY 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, ELECTRONIC, ELECTRONIC IMPULSE, FACSIMILE, MAGNETIC, ORAL, OR TELEPHONIC COMMUNICATION
OR 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.
APPLICABLE IN KENTUCKY: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSONS
FILES AN APPLICATION FOR INSURANCE CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS, FOR THE PURPOSE OF
MISLEADING, INFORMATION CONCERNING ANY MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME.
APPLICABLE IN MAINE, TENNESSEE, VIRGINIA 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 MAY INCLUDE IMPRISONMENT,
FINES OR A DENIAL OF INSURANCE BENEFITS.
APPLICABLE IN PENNSYLVANIA: 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.
APPLICABLE IN NEW YORK: 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 BE SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE STATE VALUE OF THE CLAIM FOR EACH
SUCH VIOLATION.
NAME (PLEASE PRINT/TYPE) TITLE
(MUST BE SIGNED BY THE PRESIDENT, CHAIRMAN, CEO OR EXECUTIVE
DIRECTOR)
__________
___________________________________________________
SIGNATURE DATE
SECT
ION TO BE COMPLETED BY THE PRODUCER/BROKER/AGENT
PRODUCER AGENCY
(If this is a Florida Risk, Producer means Florida Licensed Agent)
PRODUCER LICENSE NUMBER
(If this a Florida Risk, Producer means Florida Licensed Agent)
ADDRESS (STREET, CITY, STATE, ZIP)
Adult Day Care Supplemental
Page 10 of 12
© 2018 Philadelphia Consolidated Holding Corp.
07/2018
Clear Application
Print Application
.
CYBER SECURITY LIABILITY ENDORSEMENT – SUPPLEMENTAL
QUESTIONNAIRE
Name of Applicant:
Address of Applicant:
City: State: Zip:
Website: www:
Nature of Operations:
1. Annual sales or revenue: $
2. Does the Applicant collect, store or otherwise handle any Personally Identifiable Information (PII)
belonging to customers, clients, or other third parties, other than employees?
If yes, please indicate the types of Personally Identifiable Information held (check all that apply):
Yes No
a. Social Security Numbers, Bank or Other Financial Account Details, Driver’s License or
other State Identification Numbers
b. Non-public Medical or Healthcare Data, including Protected Health Information (PHI)
c. Credit or Debit Card Information
3. a. During the last three (3) years, has anyone alleged that the Applicant was responsible for
damage to their computer system(s) arising out of the operation of the Applicant’s computer
system(s)?
Yes No
b. During the last three (3) years, has anyone made a demand, claim, complaint, or filed a
lawsuit against the Applicant
alleging invasion or int
erference of rights of privacy or the
inappropriate disclosure of Personally Identifiable Information (PII)?
Yes No
c. During the last three (3) years, has the Applicant been the subject of an investigation or
action by any regulatory or administrative agency for privacy-related violations?
Yes No
d. Is the Applicant aware of any circumstance that could reasonably be anticipated to result in a
claim being made against them for the coverage being applied for?
Yes No
PI-CYBE-APP (11/16)
Page 1 of 2
Clear Application
Print Application
FRAUD STATEMENT AND SIGNATURE SECTIONS
The Undersigned states that he/she is an authorized representative of the Applicant and declares to the best of his/her knowledge and belief
and after reasonable inquiry, that the statements set forth in this Application (and any attachments submitted with this Application) are true
and complete and may be relied upon by Company * in quoting and issuing the policy. If any of the information in this Application changes
prior to the effective date of the policy, the Applicant will notify the Company of such changes and the Company may modify or withdraw the
quote or binder.
The signing of this Application does not bind the Company to offer, or the Applicant to purchase the policy.
*Company refers collectively to Philadelphia Indemnity Insurance Company and Tokio Marine Specialty Insurance Company
VIRGINIA APPLICANT: READ YOUR POLICY. THE POLICY OF INSURANCE FOR WHICH THIS APPLICATION IS BEING MADE, IF ISSUED,
MAY BE CANCELLED WITHOUT CAUSE AT THE OPTION OF THE INSURER AT ANY TIME IN THE FIRST 60 DAYS DURING WHICH IT IS IN
EFFECT AND AT ANY TIME THEREAFTER FOR REASONS STATED IN THE POLICY.
FRAUD NOTICE STATEMENTS
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 AND SUBJECTS THAT PERSON TO
CRIMINAL AND CIVIL PENALTIES (IN OREGON, THE AFOREMENTIONED ACTIONS MAY CONSTITUTE A FRAUDULENT INSURANCE ACT WHICH MAY
BE A CRIME AND MAY SUBJECT THE PERSON TO PENALTIES). (IN NEW YORK, THE CIVIL PENALTY IS NOT TO EXCEED FIVE THOUSAND DOLLARS
($5,000) AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION). (NOT APPLICABLE IN AL, AR, AZ, CO, DC, FL, KS, LA, ME, MD, MN,
NM, OK, PA, RI, TN, VA, VT, WA AND WV).
APPLICABLE IN AL, AR, AZ, DC, LA, MD, NM, RI AND WV: ANY PERSON WHO KNOWINGLY (OR WILLFULLY IN MD) PRESENTS A FALSE OR
FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR WHO KNOWINGLY (OR WILLFULLY IN MD) PRESENTS FALSE INFORMATION IN AN
APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES OR CONFINEMENT IN PRISON.
APPLICABLE IN COLORADO: 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 REGULATORY
AGENCIES.
APPLICABLE IN FLORIDA AND OKLAHOMA: 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 (IN FL, A PERSON IS GUILTY OF A FELONY OF THE THIRD DEGREE).
APPLICABLE IN KANSAS: AN ACT COMMITTED BY 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, ELECTRONIC, ELECTRONIC IMPULSE, FACSIMILE, MAGNETIC, ORAL, OR TELEPHONIC COMMUNICATION
OR 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.
APPLICABLE IN KENTUCKY: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSONS
FILES AN APPLICATION FOR INSURANCE CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS, FOR THE PURPOSE OF
MISLEADING, INFORMATION CONCERNING ANY MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME.
APPLICABLE IN MAINE, TENNESSEE, VIRGINIA 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 MAY INCLUDE IMPRISONMENT,
FINES OR A DENIAL OF INSURANCE BENEFITS.
APPLICABLE IN PENNSYLVANIA: 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.
APPLICABLE IN NEW YORK: 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 BE SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE STATE VALUE OF THE CLAIM FOR EACH
SUCH VIOLATION.
NAME (PLEASE PRINT/TYPE) TITLE
(MUST BE SIGNED BY THE PRESIDENT, CHAIRMAN, CEO OR EXECUTIVE
DIRECTOR)
____________________________
_________________________________
SIGNATURE DATE
SECTION TO BE COMPL
ETED BY THE PRODUCER/BROKER/AGENT
PRODUCER AGENCY
(If this is a Florida Risk, Producer means Florida Licensed Agent)
PRODUCER LICENSE NUMBER
(If this a Florida Risk, Producer means Florida Licensed Agent)
ADDRESS (STREET, CITY, STATE, ZIP)
PI-CYBE-APP (11/16)
Page 2 of 2
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