Fillable Application - Human Services - Comprehensive36-9277

Fill Online, Printable, Fillable, Blank Application - Human Services - Comprehensive36-9277 Form

Use Fill to complete blank online PHILADELPHIA INSURANCE COMPANIES pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Application - Human Services - Comprehensive36-9277

On average this form takes 349 minutes to complete

The Application - Human Services - Comprehensive36-9277 form is 24 pages long and contains:

  • 0 signatures
  • 150 check-boxes
  • 1327 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your Philadelphia Insurance Companies forms online.

BROWSE PHILADELPHIA INSURANCE COMPANIES FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
HUMAN SERVICES – COMPREHENSIVE APPLICATION
(Intended for Human Service risks that are complex with multiple programs/operations with revenues > $2,000,000)
Applicant Name:
Mailing Address:
City:
State:
ZIP:
Total Staff (including office, janitorial, maintenance, etc.):
Full Time:
Part Time:
SIC #:
FEIN #:
Non-Profit
For-Profit
Annual Revenue: $
Is the Applicant’s organization more than 25% owned by a private equity fund structure?
Yes
No
If yes, provide name of private equity firm:
Number of years this facility has been: In Operation:
Under current management:
Risk Management Contact:
Number:
Email:
SUBMISSION REQUIREMENTS
• ACORD applications, including Crime & Umbrella
• Statement of Values
• Photographs of the Applicant’s location(s)
SECTION I – GENERAL APPLICATION INFORMATION
1.
Please provide a narrative of the Applicant’s operations:
2.
Any mergers or operations under another name within the past five (5) years?
Yes
No
Are any mergers planned / anticipated for the coming year?
Yes
No
If yes to either, explain:
3.
Annual operating budget: $
Annual Payroll: $
Primary funding:
Federal
State
County
Other:
4.
Does the Applicant operate any locations not included in this application?
Yes
No
If yes, explain:
5.
Attach copy of current state or other governmental license(s).
If none, explain:
6.
Has the Applicant’s license ever been suspended, revoked, or placed under conditional status?
Yes
No
If yes, explain:
7.
Have there been any claims that allege negligence or failure to comply with any regulatory / licensing
guidelines?
Yes
No
8.
Indicate whether the Applicant’s employees or independent contractors provide the following services
for the Applicant’s clients:
Landscaping
Re-paving / Re-surfacing
Other:
Janitorial/Maintenance
Snow removal
9.
Does the Applicant lease, sub-lease, or rent to others?
Yes
No
If yes, does the Applicant obtain certificates of insurance?
Yes
No
10.
Does the Applicant sell goods or services to members of the public (not including clients)?
Yes
No
Products:
Annual Receipts: $
Services:
Annual Receipts: $
11.
Has the Applicant discontinued any programs in the past five (5) years?
Yes
No
If yes, explain:
12.
Does the Applicant participate in / or supervise any sports activities for the Applicant’s clients?
Yes
No
If yes, explain:
13.
Does the Applicant have field trips?
Yes
No
If yes, number per year:
Are any overnight?
Yes
No
What is the maximum distance traveled?
Are release forms obtained?
Yes
No
What are the controls that are in place?
Describe each trip:
14.
Are counseling services/therapy offered for the following target classes:
Sexual Offenders?
Yes
No
Fire Starters?
Yes
No
Sexual Predators?
Yes
No
Human Services
Comprehensive Application
Page 1 of 18
© 2019 Philadelphia Consolidated Holding Corp.
05/2019
Clear Application
Print Application
SECTION II - PREMISES / LIFE SAFETY
1.
If the building the Applicant occupies 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 Applicant have any plans for renovations or new construction?
Yes
No
If yes, explain:
3.
Are any non-ambulatory patients above the first floor?
Yes
No
4.
Does the Applicant have the following in place:
Fire alarms?
Yes
No
Central Station?
Yes
No
Security alarm?
Yes
No
Central station?
Yes
No
Smoke detectors?
Yes
No
Are smoke detectors:
Hard wired
Battery operated
5.
Number of fire extinguishers on premises:
How often and by whom are they serviced?
6.
How many means of egress are there?
Are all exits clearly marked & illuminated?
Yes
No
7.
Are all exit doors equipped with panic hardware?
Yes
No
8.
Is there a fire escape?
Yes
No
If yes, describe:
9.
Does the Applicant have a written emergency evacuation plan?
Yes
No
If yes, are the emergency evacuation procedures and floor plan posted?
Yes
No
Has the Applicant 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?
10.
Does the Applicant have emergency lighting or backup generators in the event of a power failure?
Yes
No
11.
Does the Applicant have a formal maintenance housekeeping program in place?
Yes
No
12.
Is the hot water heater set to a temperature of 120 degrees?
Yes
No
13.
Has the Applicant’s facility been inspected by an insurance company or independent inspection firm?
Yes
No
If yes, by whom?
List any deficiencies and corrective actions in the past three (3) years:
14.
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?
Yes
No
(indicate with one): COPALUM? Yes No AlumiConn?
Yes
No
Date updated:
Please supply retrofit documentation or statement from installing contractor.
SECTION III - MANAGEMENT PRACTICES
1.
Does the Applicant have sign in / sign out procedures for:
Staff
Yes
No
Clients / Residents
Yes
No
Visitors / Public
Yes
No
2.
Type of security provided for the protection of the Applicant’s clients / residents?
Guards
Video Cameras
Other:
3.
What measures are taken to monitor client activities?
4.
What precautions does the Applicant take to prevent non-staff members from accessing unauthorized
areas of the property?
5.
Does the Applicant have incident reporting procedures and / for committee reviews?
Yes
No
6.
Is the Applicant’s staff made aware of reporting procedures?
Yes
No
7.
Does the Applicant 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.
Does the Applicant have Automatic External Defibrillator(s)?
Yes
No
10.
What percentage of total staff including volunteers are trained to use the AED? %
11.
Have the police and / or fire departments been called to any of the Applicant’s premises in the
past three (3) years?
Yes
No
If yes, explain:
12.
Does the Applicant have a written and enforced no smoking policy?
Yes
No
13.
Are “no smoking” signs posted in all areas not designated for smoking?
Yes
No
14.
Does the Applicant use padded rooms?
Yes
No
15.
How often are the rooms sanitized?
16.
Does the Applicant use electric shock treatment?
Yes
No
Human Services
Comprehensive Application
Page 2 of 18
© 2019 Philadelphia Consolidated Holding Corp.
05/2019
Clear Application
Print Application
SECTION IV - PROFESSIONAL LIABILITY
1.
Hiring Practices:
2.
Does the Applicant require staff (paid and Volunteer) to complete an employment application?
Yes
No
If no, explain:
3.
Does the Applicant conduct a personal interview for each prospective staff member?
Yes
No
4.
Does the Applicant verify education references?
Yes
No
5.
Does the Applicant verify employment related references?
Yes
No
6.
Does the Applicant verify licenses and other credentials?
Yes
No
7.
Does the Applicant obtain criminal background checks on all staff members before hiring them?
Yes
No
8.
Does the Applicant require drug tests on all staff members, including drivers?
Yes
No
If yes:
Before hiring
After hiring
Random
9.
What are the Applicant’s procedures for evaluating all these reports?
10.
What actions does the Applicant take if any report is considered unfavorable?
11.
Does the Applicant share written job descriptions with all staff members?
Yes
No
12.
Name of executive director / manager:
Number of years experience in this field:
Number of years at this facility:
Specialized training or education:
13.
Are any staff members under 18 years of age?
Yes
No
If yes, list their position(s) and how they are supervised:
14.
What is the staff turnover rate for the last 12 months?
15.
Does the Applicant provide workers compensation for :
All staff members
Workshop Employees
Contractors
Consultants
16.
Is the staff required to report to the administrator all incidences that may result in a claim?
Yes
No
If yes, is a written record kept?
Yes
No
Are they reviewed?
Yes
No
17.
Are clients referred to specialists when appropriate?
Yes
No
18.
Are files maintained to protect confidentiality of clients?
Yes
No
19.
Does the Applicant do any consulting work?
Yes
No
If yes, explain:
20.
Does the Applicant’s current insurance program provide professional liability coverage?
Yes
No
If yes:
Occurrence or
Claims-made - Retroactive Date:
Limit of Liability: $
Carrier:
Effective date:
21.
Do psychiatrists prescribe experimental drugs / treatment?
Yes
No
22.
Has anyone ever had a patient who committed suicide?
Yes
No
23.
Does the Applicant’s psychiatrist get a second opinion when uncertain of the diagnosis?
Yes
No
24.
Physicians and Psychiatrists:
Name
Dr.
Dr.
Dr.
Specialty:
Board certified or eligible:
Years in practice:
License Number:
Hours per week for insured:
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
Human Services
Comprehensive Application
Page 3 of 18
© 2019 Philadelphia Consolidated Holding Corp.
05/2019
Clear Application
Print Application
SECTION IV - PROFESSIONAL LIABILITY (CONTINUED)
25.
Annual Staffing – Employees, Independent Contractors and Volunteers
Total number of:
Full time employees:
Part Time Employees:
Volunteers:
Contracted Intellectually/ Developmentally Disabled (IDD) Shared Living- Host Homes:
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
IDD In-Home Companion Care
Provider
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.
26.
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.
27.
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.
Human Services
Comprehensive Application
Page 4 of 18
© 2019 Philadelphia Consolidated Holding Corp.
05/2019
Clear Application
Print Application
28.
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: $
29.
Has the Applicant’s operations / facilities ever been accredited / certified by CARF, JCAHO, ECFA,
COA, ACHC or similar organization created to serve the Human/Behavioral/Healthcare Services
Industry?
Yes
No
If yes:
Name of Accrediting Organization:
Date of Accreditation / Certification:
Term of Accreditation / Certification:
SECTION V - ABUSE AND MOLESTATION
1.
Does the Applicant’s current insurance program include Abuse and Molestation Coverage?
Yes
No
If yes, Occurrence or Claims Made – Retro Date:
Limits 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
How often is staff trained?
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
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 - 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 reporte
d to us during the policy period or Extended Reporting Period will be
covered, 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.
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:
Human Services
Comprehensive Application
Page 5 of 18
© 2019 Philadelphia Consolidated Holding Corp.
05/2019
Clear Application
Print Application
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 VII - AUTOMOBILE
N/A
1.
Are all vehicles listed on the ACORD application titled to the applicant?
Yes
No
If no, explain:
2.
Where does the Applicant keep 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 audible backup warning device?
Yes
No
5.
Does the Applicant provide pickup or delivery of donated merchandise?
Yes
No
6.
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 does the Applicant take to prevent food spoilage?
7.
Does the Applicant transport clients / residents for other private or government agencies?
Yes
No
If yes, explain:
If yes, for a fee?
Yes
No
8.
Does the Applicant provide transportation for field trips?
Yes
No
If the Applicant does not provide the transportation, how is it provided?
If vehicles are hired for field trips, are they hired with a driver?
Yes
No
9.
If children are transported, is there a monitor to ensure their safety during transportation?
Yes
No
10.
Do the Applicant’s employees/volunteers transport children in their own vehicles?
Yes
No
If yes, how often?
11.
Are vehicles checked after passengers disembark to make sure no one is left behind?
Yes
No
12.
Do vehicles equipped for wheelchairs have tie-down belts to stabilize the wheelchair and passenger?
Yes
No
13.
Does the Applicant require seat belts to be worn by all occupants?
Yes
No
14.
Does the Applicant have a vehicle maintenance program in place?
Yes
No
15.
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:
16.
What percentage of the Applicant’s fleet is provided with these fleet telematics devices? %
SECTION VIII – DRIVERS
N/A
1.
Does the Applicant obtain a written authorization to release driver information from all of 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 21 years of age?
Yes
No
4.
How many drivers (employees and volunteers) aged 21 to 25 transport clients in agency vehicles?
5.
Do any drivers have a Commercial Driver’s License?
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, explain:
8.
Does anyone besides employees or volunteers drive the Applicant’s vehicles?
Yes
No
If yes, explain:
9.
Does the Applicant allow personal use of the Applicant’s vehicles?
Yes
No
If yes, by whom and for what reasons?
SECTION IX - HIRED AND NON-OWNED VEHICLES
N/A
1.
Does the Applicant hire vehicles?
Yes
No
If yes, what types of vehicles does the Applicant hire?
Does the Applicant obtain certificates of insurance?
Yes
No
What minimum limits does the Applicant require? $
Human Services
Comprehensive Application
Page 6 of 18
© 2019 Philadelphia Consolidated Holding Corp.
05/2019
Clear Application
Print Application
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 the Applicant require? $
SECTION X - DONATED VEHICLES
N/A
1.
What are the Applicant’s requirements for donation; e.g., age, condition, etc.?
2.
How and by whom is the vehicle delivered to the Applicant?
3.
When and how does title transfer to the Applicant?
4.
Where and under what controls are the vehicles stored?
5.
Does the Applicant repair any vehicles?
Yes
No
If yes, describe the types of repairs:
What is the training of the individuals doing the repairing?
6.
Does the Applicant keep any donated vehicles?
Yes
No
If yes, for what purpose?
7.
In what way does the Applicant dispose of the donated vehicles?
8.
If the Applicant sells the donated vehicles themselves, does the Applicant sell them “as is“ with no
guarantees?
Yes
No
9.
Does the Applicant have dealer plates?
Yes
No
If yes, how many?
SECTION XI
ADOPTION PLACEMENT AGENCY
N/A
FOSTER CARE PLACEMENT AGENCY
N/A
1.
Is the Applicant licensed in all states in which it operates?
Yes
No
List states:
2.
Are the adoption services:
Opened
Closed
Total number of anticipated adoptions in the next 12 months:
Is the adoption agency Hague approved?
Yes
No
Does Applicant do Embryo Adoptions?
Yes
No
3.
International adoptions:
Yes
No
Total number of anticipated international adoptions in the next 12 months:
4.
Total number of foster families at any one time:
5.
Anticipated number of foster children over the next 12 months:
Ages: Less than 1 year: 1-5: 6-10: Over 10:
Please identify the number of special needs foster care placement included in this number:
6.
Average number of foster children who are placed multiple times:
7.
Total number of training hours for each foster family prior to placement of first child:
8.
Total annual number of training hours for each family:
9.
Are caseworkers supervised?
Yes
No
Are decisions made by a team?
Yes
No
10.
Are home studies conducted?
Yes
No
What are staff member’s credentials?
11.
Is there a written procedure in place to analyze potential applicants?
Yes
No
12.
Are criminal records checked prior to approval of a home?
Yes
No
13.
Does the Applicant verify homeowners insurance or renters insurance?
Yes
No
14.
Does the Applicant have written procedures for dealing with a report of abuse?
Yes
No
15.
Are children given thorough medical examinations, with prior conditions noted, before they are
placed?
Yes
No
16.
Is counseling provided to the birthparents after placement?
Yes
No
17.
Are children given to adoptive parents upon release from hospital?
Yes
No
18.
Are they placed in a foster home until the time lapses for the mother to change her mind?
Yes
No
19.
Do the adoptive/foster parents receive special counseling after placement?
Yes
No
20.
Does the Applicant do follow-up visits after placement has been made?
Yes
No
Human Services
Comprehensive Application
Page 7 of 18
© 2019 Philadelphia Consolidated Holding Corp.
05/2019
Clear Application
Print Application
Are these visits unannounced?
Yes
No
How often do they occur?
When do these visits stop?
21.
What are the rights of the child’s biological grandparents?
22.
Total stipend amount paid to foster parents annually:
Foster Care annual stipend: $
23.
Total annual receipts for:
Domestic Adoptions: $
International Adoption: $
24.
Please advise additional screening criteria of Foster Parents to satisfy eligibility for special needs
placements, and indicate if follow up visits are more frequent if the placement involves a special needs
child.
25.
Are any of the Applicant’s Foster Care Services contracted to third party organizations, or, does the
Applicant conduct any foster care operations as a contractor on behalf of a separate organization?
Yes
No
If yes, please complete Section XII, Question 8 in its entirety for your Foster Care Services
SECTION XII – FOSTER CARE SERVICES PROVIDER
1.
Number of active Foster Homes / Foster Families in service:
2.
Total number of Foster Children served annually:
3.
Number of years the Applicant has operated Foster Care program:
4.
Foster Care Services (check all that apply)
Foster Home/Foster Family Screening (Studies)
Foster Care Assessments
Foster Parent counseling
Foster Home/Foster Family Certification
Case Management
Emergency Shelter
Foster Home/Foster Family Licensing
In Home support services
5.
Please list any affiliated Foster Child Placement Agencies:
a.
Do Agencies listed above carry primary liability insurance?
Yes
No
b.
Do Agencies listed above offer claim settlements under a state fund?
Yes
No
6.
Does the Applicant follow state regulations mandating Foster Care Procedures?
Yes
No
7.
Are audit procedures in place to ensure home visits are being conducted?
Yes
No
Are there standards of practice with respect to documentation and is there a method for immediate
reporting / escalation for emergency incidents?
Yes
No
8.
Are any of the Applicant’s Foster Care Services contracted to a third party organization, or, does the
Applicant conduct any foster care operations as a contractor on behalf of a separate organization?
Yes
No
If yes, please answer the below:
a.
Does the Applicant confirm that General Liability coverage, Professional Liability coverage and
Sexual Abuse or Molestation Liability coverage are carried at equal limits by all contracting
parties?
Yes
No
b.
Does the Applicant require independent contractors to add them as additional insured onto their
policy?
Yes
No
c.
Is the Applicant required by written contract to hold harmless, indemnity or add any third party
organization as additional insured?
Yes
No
d.
Do all of the Applicant’s contracting or subcontracting agreements include hold harmless &
indemnification clauses in their favor or, at a minimum, mutually exclusive?
Yes
No
e.
Does the applicant execute a hold harmless agreement with the individual foster families that
they serve?
Yes
No
f.
Please list any third party entities with whom the Applicant has contracted for foster care services
and identify what amount of the Applicant’s services are provided on a contractual basis:
Contracted Organization
Service
% of Operations
%
%
%
%
%
%
Total
%
$
Human Services
Comprehensive Application
Page 8 of 18
© 2019 Philadelphia Consolidated Holding Corp.
05/2019
Clear Application
Print Application
Note:
Contracts include those in which the Applicant is either the contractor or subcontractor.
% of operations represents foster care operations, totals should equal 100%
All contract agreements and provisions are subject to receipt and review.
SECTION XIII - FOOD BANK
N/A
THRIFT STORE
N/A
1.
Are aisles kept clear and unobstructed?
Yes
No
2.
Are goods properly stored and stacked?
Yes
No
3.
Are any goods kept outdoors?
Yes
No
4.
Are forklift operators properly trained and supervised?
Yes
No
5.
Does the Applicant provide pick up services?
Yes
No
6.
How many drop off containers and/or pick up containers does the Applicant have?
7.
Does the Applicant pick up from homes or businesses?
Yes
No
8.
What radius does the Applicant drive?
9.
Does the Applicant have a loading dock or appropriate place to unload goods?
Yes
No
10.
How often are incoming goods sorted to identify spoiled and/or hazardous goods?
11.
Are unwanted goods disposed of promptly and properly?
Yes
No
12.
If food bank, are product expiration dates monitored?
Yes
No
SECTION XIV – FOOD PREPARATION FACILITIES
N/A
1.
The food preparation equipment is:
Electric
Gas
Propane
Other:
2.
The food preparation equipment is in:
One common area
Each floor
Individual rooms
Other:
Total number of cooking areas:
3.
Who has access to the cooking area:
Staff
Clients/Residents
Visitors/Public
4.
For who is the food prepared?
Staff
Clients/Residents
Visitors/Public
If for the public, explain:
5.
Is the food properly covered, stored and served?
Yes
No
6.
Do the Applicant’s staff members supervise the cooking area?
Yes
No
7.
Are there fire extinguishers in the cooking area?
Yes
No
8.
The cooking equipment is:
Residential
Commercial
9.
Cooking equipment is equipped with:
Nothing
Hoods
Ducts
Exhaust Fans
Automatic fuel shut off controls
Automatic fire suppression system
Other:
10.
How often is the cooking equipment cleaned:
Cleaned by:
Applicant
Cleaning contractor
11.
Do the hoods have removable filters?
Yes
No
SECTION XV - SHELTERED WORKSHOP
N/A
1.
Describe work/product being performed:
2.
Does the Applicant perform industrial sub-contracted work: e.g., packaging, assembling, and actual
manufacturing of a finished product?
Yes
No
3.
What company label goes on the product?
4.
Who is the ultimate user of the product?
5.
Is there renovation or processing of used materials?
Yes
No
If yes, describe materials:
6.
Are flammables stored in proper receptacles?
Yes
No
7.
What controls are in place for painting, stripping, finishing, welding, metalworking, woodworking, etc.?
8.
Are hazardous operations separated; e.g., paint spray booths, welding booths, dipping tanks,
sawing/sanding areas?
Yes
No
If yes, describe how:
9.
When was the last time the workshop was inspected by OSHA?
Were any deficiencies noted?
Yes
No
If yes, explain:
10.
Is there proper ventilation for the work being performed?
Yes
No
Describe frequency and type of waste disposal:
11.
Quality control program in place?
Yes
No
12.
Do counselors make follow up visits to clients placed in outside employment?
Yes
No
Human Services
Comprehensive Application
Page 9 of 18
© 2019 Philadelphia Consolidated Holding Corp.
05/2019
Clear Application
Print Application
SECTION XVI - RESIDENTIAL FACILITIES
N/A
RESIDENTS
# BEDS
RESIDENTS
# BEDS
RESIDENTS
#
BEDS
Acute Skilled Care
Inpatients Crisis Center
Respite Care
Aged
Low Income Housing
Transitional Housing
Group Home
Shelter-Abuse Victims
Youth Homes
Hospice
Shelter-Homeless
Other: (specify)
Independent Living
Shelter-Other:
Other: (specify)
1.
Annual number of clients by age group:
Less than 18: 18-35: 36-65: Over 65:
2.
Annual number of clients by disability: Emotional/Behavior: Drug/Alcohol:
Developmental Disability: Intellectual Disability:
3.
Specify number of Male: Female: Co-Ed:
4.
Are residents separated?
Yes
No
How are they separated?
5.
Average length of stay:
6.
Number of non-ambulatory patients: What floor are they located on?
7.
Total number of rooms: Number of bedrooms:
8.
What was the date of the last inspection by a licensing agency?
Were there any violations or deficiencies noted?
Yes
No
If yes, explain:
9.
Does a physician screen clients prior to admission?
Yes
No
10.
Does the Applicant require a signed release form for the release of records to other individuals or
institutions?
Yes
No
11.
Are residents primarily responsible for their own basic personal care including bathing, dressing,
eating, and restroom aide?
Yes
No
12.
Is the staff trained in non-violent crisis intervention?
Yes
No
If yes, which protocol?
13.
What type of method does the Applicant use for de-escalation?
Is it approved?
Yes
No
14.
What is the Applicant’s physical restraint policy?
15.
What is the ratio of resident to staff: Day: Night:
16.
What procedures are in place for clients who are permitted to leave the premises without supervision?
17.
How many visits per month are made by a caseworker to a resident?
18.
How does the Applicant provide for the resident’s privacy and individual security?
19.
How often are rooms inspected?
Who inspects the rooms?
Does the Applicant have written procedures?
Yes
No
Does the Applicant keep a checklist?
Yes
No
20.
How often are bed checks done?
Random
Scheduled
21.
How is staff monitored?
22.
Are there security cameras monitoring operations?
Yes
No
23.
Are residents’ doors ever locked from the outside?
Yes
No
24.
Are residents allowed to cook their own meals?
Yes
No
If yes, in
Private or
Common cooking areas
25.
Does the Applicant own or operate a Nursing Home or Assisted Living Facility?
Yes
No
If yes, explain:
SECTION XVII - MEDICAL FACILITIES
N/A
1.
Does the Applicant own or operate a Medical Clinic?
Yes
No
If yes, are the facilities for:
Staff
Clients/Residents
General Public
2.
What are the facility hours?
3.
Does the Applicant provide more than immediate care/first aid?
Yes
No
If yes, explain:
4.
By job title, who staffs the facilities?
5.
Does the Applicant keep only over the counter drugs on the premises?
Yes
No
Human Services
Comprehensive Application
Page 10 of 18
© 2019 Philadelphia Consolidated Holding Corp.
05/2019
Clear Application
Print Application
If no, explain:
6.
Which staff members dispense the medications?
7.
Are the medications and equipment kept in a locked facility?
Yes
No
If no, where are they kept?
Which staff members have access?
8.
Does the Applicant have policies and procedures in place for prescribing/administering medication?
Yes
No
If yes, explain:
9.
What medical equipment does the Applicant have?
10.
Does the Applicant maintain a log of all those who receive care?
Yes
No
11.
Does the Applicant maintain medical history and care records for each individual?
Yes
No
SECTION XVIII - IN-HOME SUPPORT SERVICES
N/A
1.
Services:
Bathing
Eating
Medication management
Running errands
Blood testing
Housework
Nursing care
Social work
Changing catheters
Infusion therapy
Nutrition counseling
Speech therapy
Dressing
Laundry
Repositioning
Other:
Driving clients to & from
appointments
Meal preparation
Restroom aid
Other:
2.
How long has the program been in place?
3.
How many employees provide in-home services?
Volunteers:
4.
Number of non-ambulatory clients:
5.
Payroll for the last 12 months: $
6.
Does the Applicant sell and/or rent medical equipment?
Yes
No
Receipts sales: $ Receipts rentals: $
7.
Is all staff informed of AIDS/HIV patients?
Yes
No
8.
Does the Applicant have written procedures in place to prevent theft from the clients’ homes?
Yes
No
9.
Explain types of training the Applicant’s staff receives:
10.
Are medications administered?
Yes
No
Only as prescribed by a physician?
Yes
No
What types of medication are administered?
11.
Are visits documented?
Yes
No
How is staff monitored?
SECTION XIX- SUBSTANCE ABUSE PROGRAMS
N/A
1.
Is treatment:
Individual or
Group
Number of individual sessions annually: Number of group sessions annually:
2.
Does the Applicant provide a methadone maintenance program?
Yes
No
If yes, where is the methadone stored?
Number of methadone-only clients annually:
Number of clients with take home privileges:
Describe measures to guard against the diversion of methadone by employees and/or clients:
3.
Does the Applicant operate a detoxification unit?
Yes
No
If yes,
Medical
Other:
If Medical, does the Applicant accept clients with a history of delirium tremens (DTs) or seizures?
Yes
No
If clients are experiencing DTs or seizures, does the Applicant:
Treat them or
Refer them to a hospital?
4.
Does the Applicant operate drug/alcohol rehabilitation?
Yes
No
If yes, are these for adults only?
Yes
No
Are facilities single sex?
Yes
No
Co-ed?
Yes
No
SECTION XX - OUTPATIENT FACILITIES
N/A
TYPE OF SERVICE
# VISITS
TYPE OF SERVICE
# VISITS
1.
Annual number of clients by age group: Less than18: 18-35: 36-65: Over 65:
2.
Annual number of clients by disability: Emotional/Behavior: Drug/Alcohol:
Developmental Disability: Intellectual Disability:
Human Services
Comprehensive Application
Page 11 of 18
© 2019 Philadelphia Consolidated Holding Corp.
05/2019
Clear Application
Print Application
3.
Explain screening procedures for clients:
4.
Does the Applicant operate a clinic?
Yes
No
If yes, is it open to the public?
Yes
No
5.
Does the Applicant offer group therapy?
Yes
No
If yes, average size of group:
How often does the group meet per week?
Explain nature of problems treated/discussed:
6.
Does the Applicant operate a crisis hotline?
Yes
No
If yes, annual number of calls received:
What types of calls?
Suicide
Drug/Alcohol
Child/Spousal Abuse
Other:
What are the hours of operation for the hotline?
Is training provided?
Yes
No
Do volunteers answer calls?
Yes
No
7.
Does the Applicant provide adult day care?
Yes
No
If yes, indicate number of clients per day:
8.
Does the Applicant provide any programs for sexual offenders?
Yes
No
If yes, number of visits and describe typical offenses:
9.
Does the Applicant provide any programs for juvenile delinquents?
Yes
No
If yes, number of clients and describe typical offenses:
10.
Does the Applicant provide any services for ex-offenders or incarcerated individuals?
Yes
No
If yes, number of clients and describe typical offenses:
11.
Does the Applicant provide respite care programs?
Yes
No
If yes, maximum amount of consecutive days:
Does the Applicant:
Take all ages or
Does the Applicant specialize?
Explain:
Can parents / caretakers meet and interview the people who will be providing care?
Yes
No
How far ahead of time do parents/caretakers need to call to arrange for services?
Does the Applicant maintain records of services?
Yes
No
Does the Applicant provide follow-up to families that have been served?
Yes
No
Does the Applicant take care of other family members (e.g., siblings)?
Yes
No
What is the cost of services? $ How is payment arranged?
12.
Does the Applicant make telephone referrals?
Yes
No
If yes, annual number of calls:
13.
Are children’s services available for the children of the Applicant’s counseling patients?
Yes
No
Average number of children: Number of staff: Hours of operation:
14.
Does the Applicant operate a meal delivery service?
Yes
No
If yes, number of meals annually:
Does the Applicant charge a fee?
Yes
No
If yes, total revenue: $
SECTION XXI - THERAPEUTIC HORSEBACK RIDING
N/A
Attach a copy of medical, rider’s registration, and liability release forms.
1.
Are liability waivers signed by all parents/guardians?
Yes
No
2.
Does the Applicant follow North American Riding for the Handicapped Association standards?
Yes
No
3.
Does the Applicant or the Applicant’s instructors have regional or national riding certificates?
Yes
No
4.
Does the Applicant fasten a child to any part of the saddle?
Yes
No
5.
Are safety helmets mandatory?
Yes
No
6.
Does the Applicant provide transportation to and from the facility?
Yes
No
7.
Total annual lessons: Average size of group:
8.
What is the experience of the staff?
Human Services
Comprehensive Application
Page 12 of 18
© 2019 Philadelphia Consolidated Holding Corp.
05/2019
Clear Application
Print Application
SECTION XXII - POOL
N/A
1.
Is there a trained lifeguard on duty?
Yes
No
If yes, how many? During what hours?
2.
The pool area includes:
Hot tub
Kiddie pool
Trampoline
Whirlpool
Jacuzzi
Spa
Water slide
Other:
3.
Who uses the area?
Visitors/Public
Staff
Clients/Residents
4.
Is the pool completely fenced with a self-locking gate?
Yes
No
If yes, what is the height?
5.
Pool Location:
Indoors
Outdoors
6.
Is there a diving board?
Yes
No
If yes, what is the height?
7.
Are depths clearly marked?
Yes
No
Is walking surface around the pool non-skid and in good condition?
Yes
No
8.
Is life saving equipment readily accessible?
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.
Are swimming lessons given?
Yes
No
If yes, by whom?
13.
Is there any swim team participation?
Yes
No
If yes, explain:
14.
Is the storage of pool chemicals secured?
Yes
No
15.
How often is the pool cleaned?
16.
Does the Applicant have specific guidelines regarding closing the pool due to water contamination?
Yes
No
17.
Number of Pools:
Are all swimming pools and spas compliant with Virginia Graeme Baker Pool and Spa Safety Act?
Yes
No
If no, provide time table and action plan:
SECTION XXIII - LAKES / PONDS (Enclose copy of lake/pond rules.)
N/A
1.
Maximum depth?
2.
Is the lake fenced?
Yes
No
Are hazards within the lake roped off?
Yes
No
3.
Does the public have access to the lake area?
Yes
No
4.
Are there boat docks?
Yes
No
If yes, where?
5.
If swimming is allowed, is there a lifeguard on duty?
Yes
No
If yes, during what hours?
6.
Lake use (check all that apply):
Canoes
Ice fishing
Jet skis
Power boats (max horse power
and length allowed):
Row boats
Swimming
Fishing
Ice skating
Paddle boats
Sail boats
Water skiing
7.
Is there watercraft rental?
Yes
No
If yes, what types? Annual receipts: $
8.
Are there separate and designated usage areas?
Yes
No
9.
Is the lake/pond susceptible to freezing?
Yes
No
SECTION XXIV - PLAYGROUND
N/A
1.
Is the playground area supervised during all open hours?
Yes
No
2.
Who uses the areas?
Staff
Clients/Residents
Visitors/Public
3.
Is the play area fenced?
Yes
No
If yes, describe fencing:
4.
Describe all playground equipment including the maximum height of the equipment:
5.
Describe surface under playground equipment:
Depth of surface:
SECTION XXV - FITNESS AREA
N/A
1.
Is the fitness area supervised during all open hours?
Yes
No
2.
Is it open at any time when the Applicant’s facility is closed?
Yes
No
If yes, when and why?
3.
Who uses the area?
Staff
Clients/Residents
Visitors/Public
4.
Describe all fitness equipment and facilities (both indoor and outdoor):
5.
How often and by whom is the equipment and area inspected?
Does the Applicant keep logs of users?
Yes
No
6.
Does the Applicant require hold harmless/waivers to be signed by all users?
Yes
No
Human Services
Comprehensive Application
Page 13 of 18
© 2019 Philadelphia Consolidated Holding Corp.
05/2019
Clear Application
Print Application
SECTION XXVI - CAMPS
N/A
1.
Is written permission/waiver of liability obtained from every child’s parent or guardian?
Yes
No
2.
Does the camp provide overnight services?
Yes
No
If yes, what is the average length of stay?
3.
Total number of days in operation annually: Number of children at each camp:
4.
Number of staff members at each camp:
5.
What are the qualifications of staff working with children?
6.
Are sleeping quarter’s co-ed?
Yes
No
Are restrooms/showers co-ed?
Yes
No
7.
If well water, how often is it tested?
8.
Indicate and describe if any of the following exposures exists in the camp operations:
Archery
Guns
Jet skis
Motor boats
Obstacle course
Water skiing
Diving boards
Horses
Lakes
Pools
Rock climbing
Other:
SECTION XXVII – ADULT DAY CARE
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 XXVIII - PLANNED EVENTS / FUND RAISERS**
N/A
** If Insured has more than five (5) events planned for the upcoming policy period, photocopy this page and add additional events.
QUESTIONS
EVENT #1
EVENT #2
EVENT #3
EVENT #4
EVENT #5
Describe the type of event*
* Insert letter for type of event: A = Wine tasting B = Golf outing C = Other sporting event (specify) D = Picnic E = Banquet
F = House tour G = Bingo H = Walkathon I = Fashion show J = Concert (specify) K = Other (specify)
Date(s) the event is held.
Daily hours of operation.
Total anticipated revenue.
$
$
$
$
$
Held at Applicant’s premises? If not, specify where it
is held.
Number of participants.
Number of staff members.
Are certificates of insurance obtained from everyone
providing products / services?
If there will be drinking at the event, how does the
Applicant control the amount allowed?
Who provides / serves the alcohol?
Liquor license required?
Are the bartenders hired by the Applicant or by the
place where the event is held?
Do the bartenders know TIPS?
If applicable, list all sporting activities to be a part of
this event.
What safeguards are in place to prevent spectator
injury?
Do participants sign a waiver?
Do participants show proof of personal health
insurance?
Human Services
Comprehensive Application
Page 14 of 18
© 2019 Philadelphia Consolidated Holding Corp.
05/2019
Clear Application
Print Application
SECTION XXIX - WINTER WEATHER FREEZE-UP PROTECTION
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
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 temperature?
Yes
No
N/A
1.
If no, please describe freeze prevention measures (e.g. temperature
monitoring, heat trace, full insulation on piping or roof):
iv.
If yes, is the testing & inspection by qualified sprinkler contractor completed within
past 12 months & includes a formal winterization review?
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):
6.
General Comments:
Human Services
Comprehensive Application
Page 15 of 18
© 2019 Philadelphia Consolidated Holding Corp.
05/2019
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
SE
CTION 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)
Human Services
Comprehensive Application
Page 16 of 18
© 2019 Philadelphia Consolidated Holding Corp.
05/2019
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 agains
t the Applicant all
eging invasion or interference 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
SE
CTION 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)
PI-CYBE-APP (11/16)
Page 2 of 2
Clear Application
Print Application
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Application - Human Services - Comprehensive36-9277

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 2 July 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document