Fillable Application - Residential Care Supplemental36-15854

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Application - Residential Care Supplemental36-15854

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RESIDENTIAL CARE SUPPLEMENTAL APPLICATION
Applicant Name:
E-mail Address:
Website Address:
For-Profit
Non-Profit
Annual Budget: $
Annual Payroll: $
SIC code: FEIN:
Yes
No
If yes, provide name of private equity firm:
Year business established: Years under present management:
Name of executive director / administrator:
Number of years at facility:
Risk Management Contact:
Phone:
Email:
REQUIREMENTS FOR SUBMISSION
• Completed ACORD applications
• Copy of facility evaluation
• Copy of the current license
• Currently valued company loss runs for this policy period plus three year’s prior
SECTION I – GENERAL INFORMATION
1.
Are ALL operated residential facilities licensed?
Yes
No
2.
Has Applicant’s license ever been suspended, revoked, or placed under conditional status?
Yes
No
3.
Date of last state inspection:
Any inspection violations/deficiencies noted?
Yes
No
Provide date compliance completed:
4.
Have there been any claims that allege negligence or failure to comply with any regulatory / license
guideline?
Yes
No
If yes, please explain on a separate sheet of paper.
5.
Any mergers or operations under another name within the past five (5) years?
Yes
No
6.
Primary funding source:
Private
SSI/SSP
Other:
7.
Does the Applicant operate any locations not included in this application?
Yes
No
If yes, describe:
8.
List all association memberships or affiliations:
9.
Are counseling services/therapy offered for the following target classes:
Fire Starter?
Yes
No
Sexual Offenders?
Yes
No
Sexual Predators?
Yes
No
SECTION II – MANAGEMENT PRACTICES
1.
Does the Applicant have sign in/out procedures for:
Staff?
Yes
No
Clients/Residents?
Yes
No
Visitors/Public?
Yes
No
2.
Describe precautions utilized to prevent unauthorized access to facility(s):
3.
Service Level / Client to Staff Ratio Definitions (select all that apply):
These clients do not live in licensed residential care homes as they are very high functioning. Most hold jobs or
attend day programs. (Level 1 – CA Only)
6 to 1 staff ratio (6 residents to 1 staff person minimum). Residents want or need a little supervision – only
reminders to do things. Supervision for safety reasons only. Most residents attend day programs or attend
sheltered workshops. (Level 2 – CA Only)
3 to 1 staff ratio. Behavior issues maybe involved (i.e. not listening, assistance with physical needs such as
toileting, bathing). Most residents attend day programs or sheltered workshops. (Level 3 – CA Only)
Direct assistance needed for physical and/or behavioral issues. Most residents attend day programs or sheltered
workshops. Care, supervision, and professionally supervised training for persons with deficits in self-help skills,
and/or severe impairment in physical coordination and mobility, and/or severely disruptive or self-injurious
behavior. Service level 4 subdivided into levels 4 (a) through 4(i), in which staffing levels are increased to
correspond to escalating severity of disability levels. (Level 4 – CA Only)
Has a 3 to 1 staff ratio (additional hours may be required if over 3 residents in home (Level 4 (a-e) – CA Only)
Has a 2 to 1 staff ratio (Level 4 (f-i) – CA Only)
Residential Care Supplemental
Page 1 of 8
© 2019 Philadelphia Consolidated Holding Corp.
05/2019
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SECTION III – RESIDENTIAL FACILITIES
(photocopy this section for each additional location)
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:
Average Occupancy:
2.
Annual number of clients by disability:
24-hr Constant Care Required:
Alzheimer’s/Dementia:
Blind:
Deaf:
Developmental Disability:
Drug/Alcohol:
Emotional/Behavior:
Intellectual Behavior:
Non-Ambulatory:
Traumatic Brain Injury:
3.
Is specific training provided for all staff caring for these ailments?
Yes
No
4.
Does the Applicant train staff to recognize the need for increased level of care and have procedures
in place for properly reassigning clients to more suitable facilities?
Yes
No
5.
Resident elopement/unauthorized leave prevention (check all that apply):
Exit doors locked to residents
Wristband sensor w/alarm
Exit doors alarmed to residents
6.
How often are residents checked or monitored to ensure that they are at the facility or have returned
to the facility?
7.
Specify number of:
Male:
Female:
Co-ed:
8.
Are residents separated?
Yes
No
How are they separated?
9.
Average length of stay:
10.
Total number of rooms:
Number of bedrooms:
11.
Does a physician screen clients prior to admission?
Yes
No
12.
Does the Applicant require a signed release form for the release of records to other individuals or
institutions?
Yes
No
13.
Are residents primarily responsible for their own basic personal care including bathing, dressing,
eating, and restroom aide?
Yes
No
14.
Is the staff trained in non-violent crisis intervention?
Yes
No
If yes, which protocol?
15.
What type of method does the Applicant use for de-escalation?
Is it approved?
Yes
No
16.
What is the Applicant’s physical restraint policy?
17.
What is the ratio of resident to staff:
Day:
Night:
18.
What procedures are in place for clients who are permitted to leave the premises without supervision?
19.
How many visits per month are made by a caseworker to a resident?
20.
How does the Applicant provide for the resident’s privacy and individual security?
21.
How often are rooms inspected?
Who inspects the room?
Does the Applicant have written procedures?
Yes
No
Does the Applicant keep a checklist?
Yes
No
22.
How often are bed checks done?
Random
Scheduled
23.
How is staff monitored?
24.
Are there security cameras monitoring operations and residents?
Yes
No
25.
Are resident’s doors ever locked from the outside?
Yes
No
Residential Care Supplemental
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05/2019
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26.
Are residents allowed to cook their own meals?
Yes
No
If yes, in:
Private or
Common cooking areas
27.
Does the Applicant own or operate a Nursing Home or Assisted Living Facility?
Yes
No
If yes, please explain:
28.
Is there a pool?
Yes
No
If yes, who uses the pool:
Visitors
Staff
Clients/Residents
Is the pool completely fenced in with a self-locking gate?
Yes
No
If yes, what is the height?
Is there a diving board?
Yes
No
Is the staff trained in water safety?
Yes
No
SECTION IV – PROFESSIONAL LIABILITY / STAFF
1.
Does the Applicant create written job descriptions for each employee and share with staff?
Yes
No
2.
Does the Applicant train and require all staff to report all incidents to management?
Yes
No
Is a written record of all incidents kept?
Yes
No
Does management investigate each incident and record findings in writing?
Yes
No
3.
Does the Applicant’s current insurance program include professional liability?
Yes
No
If yes, is it:
Occurrence or
Claims Made – Retro Date:
Limit: $
Carrier:
Effective Date:
4.
What is the staff turnover ratio for the last twelve (12) months?
5.
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
Residential Care Supplemental
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© 2019 Philadelphia Consolidated Holding Corp.
05/2019
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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.
6.
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.
7.
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.
SECTION V - CONSULTANTS/INDEPENDENT CONTRACTORS
1.
Please indicate which of the following contracted service providers are utilized:
Dentist
Nurse Practitioner
Physicians
Other:
Home Health Aides
Optometrist
Psychiatrist
2.
Does the Applicant’s current insurance program include professional liability?
Yes
No
3. Are there written agreements with independent contractors? Yes No
4.
Are certificates of malpractice/liability insurance obtained and maintained for all contracted service
providers (independent contractors)?
Yes No
5. Please indicate the limits of liability: $
SECTION VI – LIFE SAFETY
Do all the Applicant’s facilities (buildings) have the following life safety features?
1.
Fire alarms?
Yes
No
2.
Smoke detectors: Hardwired
Yes
No Battery operated
Yes
No
3.
Emergency lighting?
Yes
No
4.
Ceiling sprinklers?
Yes
No
5.
Are all areas of buildings with wet pipe sprinkler systems (hidden or unhidden) maintained at a
minimum temperature of 40° F, and / or provided with proper insulation or heat tracing to prevent
pipe freeze-ups?
Yes
No
6.
Are evacuation routes posted throughout the building?
Yes
No
7.
In the event of an evacuation, has the Applicant established a central meeting point outside the
building?
Yes
No
8.
Are exit signs illuminated?
Yes
No
9.
How often are the fire drills held?
10.
Are there at least two exit doors per building?
Yes
No
11.
Are exit doors equipped with panic hardware?
Yes
No
12.
Is smoking permitted inside the premises?
Yes
No
13.
Are any non-ambulatory residents located above the 1
st
floor?
Yes
No
If yes, provide number of residents and which floor they reside on.
14.
Does the property have aluminum wiring?
Yes
No
If yes, has it been retrofitted with one of the following PHLY approved connectors by a licensed
Electrician? (indicate which one): COPALUM? Yes No AlumiConn?
Yes
No
Residential Care Supplemental
Page 4 of 8
© 2019 Philadelphia Consolidated Holding Corp.
05/2019
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SECTION VII – ABUSE & MOLESTATION
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
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 VIII - AUTOMOBILE
N/A
1.
Are all vehicles listed on the ACORD application registered to the applicant?
Yes
No
If no, explain:
2.
Are vehicles for more than 8 passengers equipped with an audible backup warning service?
Yes
No
3.
How many drivers use personal vehicles for business? Volunteers: F/T*:
P/T**:
*F/T = Full Time – over 20 hours per week / **P/T = Part Time – up to 20 hours per week
4.
Does the Applicant require employees and volunteers to carry and show evidence of personal
insurance if they use their personal vehicle in the business?
Yes
No
5.
What limits are required? $
6.
Does the Applicant run MVRs on employees?
Yes
No
If yes, how often?
7.
Does the Applicant have a driver safety training program?
Yes
No
8.
Are all drivers at least 21 years of age?
Yes
No
9.
Do any drivers between the ages of 21 and 25 operate vehicles with eight (8) passenger seating
capacity or greater?
Yes
No
10.
Does the Applicant have a formal vehicle maintenance program in effect?
Yes
No
11.
Does the Applicant transport clients?
Yes
No
a.
Is training provided for new employees and/or volunteers prior to their transporting clients?
Yes
No
b.
Are vehicles checked after passengers disembark to make sure no one is left behind?
Yes
No
c.
Do vehicles equipped for wheelchairs have tie-down belts to stabilize the wheelchair and
passenger?
Yes
No
d.
Does the Applicant require seat belts to be worn by all passengers?
Yes
No
12.
Does the Applicant transport clients/consumers for other private or government agencies?
Yes
No
If yes, please explain:
If yes, for a fee?
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? %
Residential Care Supplemental
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© 2019 Philadelphia Consolidated Holding Corp.
05/2019
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SECTION IX – CLAIMS MADE
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
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.
N/A (Please proceed to signature section)
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:
Residential Care Supplemental
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05/2019
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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 winterizati
on 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):
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
m
onitoring, heat trace, full insulation on piping or roof):
6.
General Comments:
Residential Care Supplemental
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05/2019
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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
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)
Residential Care Supplemental
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