Fillable Application - Sleep Centers And Laboratories36-9281

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Application - Sleep Centers And Laboratories36-9281

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SLEEP CENTERS AND LABORATORIES
SUBMISSION REQUIREMENTS
• Completed, signed, and dated PHLY Sleep Center
and Laboratories Supplemental
• Currently valued company loss runs for this policy
period plus three year’s prior
• Completed ACORD Applications • Copy of the current license
SECTION I – GENERAL INFORMATION
1. List all the states the Applicant is licensed to do business in:
2. Has the Applicant’s license ever been suspended, revoked or restricted? Yes No
3. Please provide a listing of all subsidiaries, description of operations and percentage of ownership:
Name Description % Owned
%
%
%
%
4. Prior Insurance:
Insurance Carrier
Policy
Period
Policy
Number
Limits of
Liability
Premium
Amount
Coverage type
(Occurrence /
Claims Made)
5. Has the Applicant’s insurance coverage ever been canceled or refused renewal? Yes No
6. Within the past five years, has the applicant acquired, sold or discontinued any operations? Yes No
7. Is this an overnight facility? Yes No
If yes, how many beds?
8. Does the applicant perform any treatment or services on the applicant’s premises? Yes No
If yes, please describe:
9. Is the Applicant’s facility accredited? Yes No
If yes, by whom?
10. Is the Applicant certified for Medicare reimbursement? Yes No
11. Total Annual Gross Receipts (last 12 months) $
Total Annual Gross Receipts (next12 months) $
12. Gross Receipts by Category:
Sleep Studies $
Rental/Sale of Equipment $
All other (describe) $
Partnership
Fax Number:
Years in Business:
Corporation Other:
Risk Management’s Phone:
Applicant:
Location Address:
Mailing Address (if different than above):
Phone Number:
FEIN:
Applicant is an: Individual
Description of Operations:
Risk Management Contact:
Risk Management Email:
Sleep Centers and Laboratories
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13.
Number of Treatments/Procedures:
Treatment/Procedure
Prior Year
14.
Does the Applicant sponsor any sporting, fundraising or social events?
Yes
No
If yes, please explain:
15.
Does the Applicant sell, rent or lease any medical supplies and/or equipment?
Yes
No
If yes, please explain:
16.
Is the Applicant named as an additional insured or vendor on the manufacturer’s policy for any/all
products?
Yes
No
SECTION II – CONTRACTUAL AGREEMENTS
1.
Is the Applicant’s organization:
privately owned / “freestanding” or
affiliated / owned by another organization
If affiliated / owned by another organization please select one of the following:
Hospital
University
Nursing Home
Other entity (explain)
2.
Does the Applicant enter into contractual agreements (i.e. hospitals, nursing homes)?
Yes
No
3.
Do contractual agreements contain/hold harmless or indemnification clauses favorable to the
applicant?
Yes
No
4.
Is the Applicant required to name any other entity as an additional insured?
Yes
No
If yes, please list the name and address of each entity and the business relationship.
5.
Have any physicians with a financial relationship to the applicant ever made any medical referrals
to the applicant?
Yes
No
If yes, please attach an explanation (including name of physicians, details of financial relationship
and type of referrals).
“Financial Relationship” means all ownership of investment interests, compensation arrangements and
medical directorships with applicant.
SECTION III – COVERAGE REQUEST
1.
Professional Liability:
Occurrence
Claims Made
*Prior Acts Date:
(Attach copy of Prior Claims Made Policy Declaration if requesting Prior Acts)
2.
If the Applicant checked off claims-made, please check the appropriate box below:
Applicant has purchased the Extended Reporting Period Endorsement on their prior policy.
Name of carrier:
Applicant understands that they elected not to purchase the Extended Reporting Period Endorsement on
their previous claims-made policy, and they also have elected not to purchase the prior Acts Coverage on
the new policy. They understand that they will be uninsured for the period in which their prior claims-made
policy existed. Furthermore, the Applicant understands that because of this there will be a gap in the
Applicant’s insurance coverage.
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SECTION IV – STAFFING
2. 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.
3. 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.
1. Annual Staffing – Employees, Independent Contractors and Volunteers
Total number of: Full time employees: Part Time Employees: Volunteers:
Staffing
# of Employees # of Contracted
Total Annual Volunteer
Hours Worked
FT PT FT PT
Psychologist
Medical Director (Admin Only)
Nurse Practitioner
Physician Assistant
Pharmacist
Paramedic EMT
Psychiatrist
Physician-Hospice
Pediatrician
Physician-No Surgery
Dentist
Optometrists/Ophthalmologist
Licensed Social Worker
Sociologist
Registered Nurse (RN)
Licensed Practical Nurse (LPN)
Physical Therapist
Optician
Orthotics & Prosthetics (O&P)
Certified Practitioner
Counselor (Guidance, Vocational)
Social Worker
Occupational Therapist
Speech Therapist
Clergy / Rabbi / Pastor
O&P Certified Technician
Teacher
Nutritionist / Dietician
Residential Manager
Home Health Aide
Day Care Worker
O&P Certified Fitter
O&P Certified Assistant
Adoptions
Foster Care
*Other (describe):
*Other (describe):
F/T = Full Time – over 20 hours per week/ P/T = Part Time – up to 20 hours per week.
*Please describe “other” staff positions not listed in the above chart in the provided area.
Sleep Centers and Laboratories
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4.
Please provide the following information for the Medical Director and Physicians that provide services at the
Applicant’s facility:
Name
Insurance
Carrier
Policy
Limits
State/Lic. #
Specialty /
Board
Certified
Employee
or
Contractor
Hours per
month
5.
Check all the following that apply if obtained, verified, and filed as part of each employee screening
and hiring process:
Application
Education / Competency
Multi-Sate Registry
Drug / HIV / Hep.Testing
Licenses / Annual Confirmation
6.
Does the Applicant question prospects about previous claims or suits?
Yes
No
7.
Are the Applicant’s employees required to actively participate in continuing education?
Yes
No
8.
Does the Applicant verify any pending license suspensions, revocations, or pending disciplinary
actions?
Yes
No
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:
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 VI – RISK MANAGEMENT
1.
What management body oversees the quality of patient care? (i.e. medical directory, advisory board, etc.)
2.
Does the Applicant have a formal written quality assurance and risk management program?
Yes
No
If yes: Person Responsible:
Title:
Sleep Centers and Laboratories
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3.
Please indicate if the following policies and procedures are established and adhered to by all staff,
including contractors and volunteers.
a.
Test result interpretation in lab’s name:
Yes
No
b.
Consultation in lab’s name:
Yes
No
c.
Therapy or any treatment procedures:
Yes
No
d.
Medical, genetic or drug research:
Yes
No
e.
Any type of environmental analysis:
Yes
No
f.
Solely mobile in nature:
Yes
No
g.
Any services to the public (health fairs, shopping mall exhibits, etc.)
Yes
No
If the Applicant answered “No” to any of the above questions, please provide an explanation:
SECTION VII – PREMISES / LIFE SAFETY
1.
Central Station Alarm System for: Fire, Smoke and Break-in?
Yes
No
2.
Monitored 24 hours a day?
Yes
No
3.
Are all stairs covered with anti-slip treads?
Yes
No
4.
Are handrails provided on all stairways?
Yes
No
Hallways?
Yes
No
5.
Are parking lots free of debris and are surfaces smooth?
Yes
No
6.
Is exterior of building well lit?
Yes
No
7.
Are the edges of curbs, sidewalks and steps color-coded to identify raised surfaces?
Yes
No
8.
Who is responsible for the maintenance of building, such as snow/ice removal?
9.
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
SECTION VIII– TESTING RESULTS
1.
Who is interpreting or analyzing the results? Who employs this individual?
2.
Is there a fee for the service?
Yes
No
3.
Are tests administered by a certified Polysomnographic Technologist (PST)?
Yes
No
Does the PST score the test?
Yes
No
4.
Where is the testing done? (check all that apply):
DME Facility
Hospital
Patient’s Home
Sleep Lab
a.
Please enclose a list of facility locations
b.
How many patients stay overnight at one time?
c.
What is the ratio of staff to patients?
5.
Are professional employees and/or independent contractors required to carry their own insurance?
Yes
No
a.
Does Applicant keep Certificates of Insurance on file?
Yes
No
b.
Does Applicant request to be added on as an additional insured on their policy?
Yes
No
6.
Are any drugs or medications provided, used, sold or prescribed?
Yes
No
a.
If Yes, please describe:
b.
If yes, prescribed by whom?
SECTION IX – CLAIMS
IMPORTANT: This section must be completed in its entirety. Any malpractice claims or suits in which Applicant has
been involved in during the past seven (7) years must be reported. Any incidents or circumstances of which the
Applicant is aware of that are likely to give rise to a claim must be reported. Provide copies of suit papers or claimant
letters. If the claim is closed, provide copies of settlement or judgment documents or order of dismissal. If reporting
more than one incident, suit or claim, photocopy this form for each.
1.
Name of Patient:
2.
Allegation/Incident:
3.
Incident Date:
Report Date:
Sleep Centers and Laboratories
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4.
Was suit filed?
Yes
No
5.
Jurisdiction?
6.
Names of Co-Defendants:
N/A
7.
Insurance Carrier(s) covering claim:
8.
Policy Period(s):
9.
Final outcome of claim (This information may be obtained by inquiry of your current or past insurer. Please note
that you must personally contact your insurance carrier.)
Open: (still pending)
Indemnity reserve placed by insurer: $
Defense cost reserve placed by insurer: $
Closed:
Method of closing:
Dismissed
Withdrawn
Judgment
Settlement
Total Expenses:
Amount of settlement or judgment: $
Defense cost: $
10.
Please provide summary of clinical facts. Applicant’s summary must provide an adequate description of their care
and treatment of the patient to allow proper evaluation. Please include the following: (Use additional sheets if
necessary.)
a.
Patient age and sex:
b.
Initial patient condition and diagnosis:
c.
Condition and diagnosis at time of incident:
d.
Dates and description of treatment rendered:
e.
Condition of patient subsequent to treatment:
f.
Copies of patient’s records and progress notes as appropriate.
SECTION X – 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)
Policy Effective Date:
Line of Business:
1.
Within the past 5 (five) years has the Applicant given written notice under the provisions of any
current or prior policy providing similar insurance of any claim or of any specific facts or
circumstances which might give rise to a claim being made against the Applicant?
Yes
No
If yes, please provide details:
2.
With respect to the coverages applied for, upon inquiry of any of person qualifying as a Named
Insured under the proposed policy, are there any facts, circumstances, or situations which might give
rise to a claim under the coverage(s) for which the Applicant is applying?
Yes
No
If yes, please provide details:
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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
SECTION TO BE C
OMPLETED 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)
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.
CYBER SECURITY LIABILITY ENDORSEMENT – SUPPLEMENTAL
QUESTIONNAIRE
Name of Applicant:
Address of Applicant:
City: State: Zip:
Website: www:
Nature of Operations:
1. Annual sales or revenue: $
2. Does the Applicant collect, store or otherwise handle any Personally Identifiable Information (PII)
belonging to customers, clients, or other third parties, other than employees?
If yes, please indicate the types of Personally Identifiable Information held (check all that apply):
Yes No
a. Social Security Numbers, Bank or Other Financial Account Details, Driver’s License or
other State Identification Numbers
b. Non-public Medical or Healthcare Data, including Protected Health Information (PHI)
c. Credit or Debit Card Information
3. a. During the last three (3) years, has anyone alleged that the Applicant was responsible for
damage to their computer system(s) arising out of the operation of the Applicant’s computer
system(s)?
Yes No
b. During the last three (3) years, has anyone made a demand, claim, complaint, or filed a
lawsuit against the
Applicant alleging inv
asion 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)
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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
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)
PI-CYBE-APP (11/16)
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Application - Sleep Centers And Laboratories36-9281

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Completed 2 July 2020

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