Fillable Application - Healthcare Auto Supplemental36-9042 (Philadelphia Insurance Companies)

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Application - Healthcare Auto Supplemental36-9042 (Philadelphia Insurance Companies)

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HEALTHCARE AUTO SUPPLEMENTAL APPLICATION
Applicant’s Name:
Address:
City:
State:
Zip:
Telephone:
SECTION I – APPLICANT INFORMATION
1.
Type of business: (Check all that apply)
Active Adult Community
Hospital
Medical Facility
Nursing Home
Rehabilitation Facility
Skilled Nursing Facility
Visiting Nurses Program
Other Describe:
2. For each category below, please advise how many persons operate a personal vehicle or company
vehicle and for what purpose: (other than home health care service)
# of Employees:
For what purpose:
# of Volunteers:
For what purpose:
# of Independent Contractors:
For what purpose:
3.
Do any of the scheduled vehicles have a mechanical lift?
Yes
No
If yes, which ones:
4.
Are all the drivers trained on the proper use of these lifts?
Yes
No
5.
Do vehicles equipped for wheelchairs have tie-down belts to stabilize the wheelchair and
passenger?
Yes
No
6.
Does the Applicant hire / use independent contractors to provide home health care service or other
patient services?
Yes
No
7.
During the most recent year, how many of the Applicant’s employees or independent contractors
provided home health care services on behalf of the insured?
# of employees:
# of independent contractors:
8.
If Applicant has visiting nurses or home care providers, is there a minimum age requirement?
If yes, what is the minimum age requirement?
Yes
No
9.
If home caregivers or visiting nurses are considered independent contractors, is there a signed
contract in place?
Yes
No
If yes, please provide a copy of the current contract in force.
10.
Does the contract require the independent contractors to provide a certificate of insurance naming
our insured as an additional insured under their policy?
Yes
No
If yes, please provide a copy of the current certificate of insurance from each independent
contractor used.
Healthcare Auto Supplemental
© 2018 Philadelphia Consolidated Holding Corp.
Page 1 of 3
12/2018
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11. Does the contract require the independent contractors to carry a minimum Automobile Liability limit
of insurance?
Yes
No
If yes, what is the limit of insurance? $
12.
Total amount expensed in the previous fiscal period, as reported to the I.R.S. for employee /
volunteer / independent contractors mileage reimbursement: $
13.
Does the Applicant require all employees who use their own vehicles for company business to carry
personal auto insurance?
Yes
No
If yes, what limits are required?
14.
Does the Applicant obtain certificates of insurance or a copy of the current declarations page from
the employees’ automobile insurer?
Yes
No
If yes, who maintains these records?
15.
Is there a process or procedure in place that requires an employee to notify the company if their
Personal Automobile Policy has lapsed or been cancelled?
Yes
No
16.
How many vehicles (cars, vans, trucks, or tractors) are hired, rented or borrowed each year?
# of short-term leases (less than 6 months):
# of short-term rentals (include airport rentals):
17.
Other than airport rentals, for what purpose are the hired, rented or borrowed vehicles used?
18.
Other than airport rentals, what is the total estimated cost for all hired vehicles for the most recent
fiscal period? $
19.
Who is providing primary automobile liability and automobile physical damage for the rented / hired /
borrowed vehicles? (e.g. rental company, leasing firm, employee, insured, credit card)?
20.
Is there a formal, written Fleet Safety Program in place?
Yes
No
21.
Are Motor Vehicle Reports ordered prior to hiring new drivers?
Yes
No
22. Are Motor Vehicle Reports ordered on all vehicle operators annually including independent
contractors?
Yes
No
23.
Are random drug tests conducted on employees / independent contractors?
Yes
No
24.
Is there a company policy on youthful drivers with 5 or less years driving experience using company
vehicles?
Yes
No
25.
Are family members allowed to use the company owned vehicles?
Yes
No
26.
Does the insured’s application include independent contractor’s driving information?
Yes
No
Healthcare Auto Supplemental
© 2018 Philadelphia Consolidated Holding Corp.
Page 2 of 3
12/2018
Print Application
Clear 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 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)
Healthcare Auto Supplemental
© 2018 Philadelphia Consolidated Holding Corp.
Page 3 of 3
12/2018
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Application - Healthcare Auto Supplemental36-9042 (Philadelphia Insurance Companies)

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