Fillable Application For Home Health Care Basic Non-Nursing Services (Colonial General Insurance Agency, Inc)

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Application For Home Health Care Basic Non-Nursing Services (Colonial General Insurance Agency, Inc)

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Page 1 of 4 A102 (04/10)
Member Companies of Western World Insurance Group
Application For
Western World Insurance Company
Home Health Care Basic Non-Nursing
Services
Tudor Insurance Company
1. Name of Applicant:
2. Individual Corporation Partnership Other (Explain)
Date Established
3. Street Address:
City: State: Zip:
Applicant’s Web Site Address:
4. Provide full name(s) of individual and partners.
5. What state/s are you licensed or certified in? Provide details of what your license/certification allows you to do.
6. Has applicant’s license ever been suspended or revoked? Yes No
Has applicant ever been investigated by the State Health Dept., State Licensing Board or other
governmental body?
Yes No
If yes to either question above, provide full details on Attachment to A102.
7. Is applicant’s operation Medicare approved?
Yes No Medicare sales? $
8. Is applicant accredited by any of the following?
National Homecaring Council
Yes Joint Commission on Accreditation of Healthcare Organizations Yes
National Association of Home Care Yes Community Health Accreditation Program Yes
9. Sales from employees: $ Sales from independent contractors: $
Sales from non-nursing operations: $ Total Sales: $
10. Do employed nurses have their own Professional Liability coverage? Yes No
Limits Required? $
Does the applicant require Certificates of Insurance from all nursing (RNs, LPNs) independent contractors?
Yes No
Limits Required? $
11.
Applicant’s premium is adjustable based on gross sales. Our auditor will verify applicant’s gross sales.
If this information is kept by the applicant’s accountant, please provide accountant’s name, address and telephone number.
If this information is kept by the applicant, please provide the telephone number and address where the records are kept.
If you are not normally at this location during working hours, please provide a beeper number or
telephone number where you can be reached:
Applicant’s telephone number if not previously given:
12. Prior coverage:
Insurance
Company
Year Premium
Type? Occurrence/
Claims Made
Any Claims
(Check One)
Description
Occ CM Yes No
Occ CM Yes No
Occ CM Yes No
Occ CM Yes No
Occ CM Yes No
13. Is the applicant aware of any circumstances which may result in a claim? Yes No
If yes, provide full details on Attachment to A102.
14. Does the applicant want the policy to cover employees? There is a premium charge.
Yes No
(Note: The policy already protects the applicant for the acts of his/her employees.)
15. Are applicant’s employees or independent contractors responsible for monitoring any equipment?
Yes No
If yes, please provide full description.
Check if continued on Attachment to A102.
Page 2 of 4 A102 (04/10)
16. Are employees required to complete daily work reports? Yes No
Does applicant utilize a formal Quality Assurance/Risk Management program? Yes No
Does applicant conduct patient/client surveys? Yes No
Is there an informed consent process in place? Yes No
Are there written policies in place for:
Drug administration procedures?
Yes No Patient acceptance? Yes No
Emergencies in the field? Yes No Patient rights? Yes No
Employee training?
Yes No Physician orders? Yes No
Food preparation? Yes No Proper lifting? Yes No
Handling of complaints?
Yes No Reporting of suspected physical/sexual abuse? Yes No
Medical equipment training? Yes No Termination of Care? Yes No
If th
e answer to any question is no, refer risk to Company.
17.
Please provide details of employed
or contracted personnel:
Number
Employed
Number
Contracted
Contractors
Ins. Limits
Required
Percentage working in:
Hospital
Nursing
Home* Home
Aides/Homemaker Health Aides
LPN’s
RN’s
Home Companions
Certified Nursing Assistants
Others (Specify)
Percentage of Clients under 18 years of age? % Percentage of Clients over 65 years of age? %
* If yes, is contract with client for private duty work? Yes No If no, please explain on Attachment to A102.
18. Are the following background checks performed?
All prior employers?
Yes No Home telephone verification? Yes No
All educational institutions? Yes No Professional licensing verification? Yes No
Driver’s license information?
Yes No Residency information? Yes No
Drug screening required? Yes No Sex offender registry search? Yes No
Federal, State (if possible) and County
criminal record search?
Yes No Social Security No. verification? Yes No
If the answer to any question is no, refer risk to Company.
19.
Is 24 Hour Service provided?
Yes No If Yes, Percent of Operations %
If Yes, is this Live-in?
Yes No Shift Work? Yes No
20. Please describe services performed by any other professionals.
Check if continued on Attachment to A102.
21. Please list any medical equipment applicant supplies to clients.
22. Does the applicant sell or rent equipment to clients? Yes No
If yes, complete Application A-17.
23. Please provide details of licensing or certification needed for this operation.
Check if continued on Attachment to A102.
24.
Limits of Insurance Requested
General Aggregate Limit (Other than Products-Completed Operations) $
Products-Completed Operations Aggregate Limit $
Personal and Advertising Injury Limit $
Each Occurrence Limit $
Damage to Premises Rented to You (Up to $100,000 limit available) $ Any One (1) Premises
Medical Expense Limit (Up to $5,000 limit available) $ Any One (1) Person
Each Professional Incident Limit (if applicable) $
25. Effective Dates Desired – From: To:
Page 3 of 4 A102 (04/10)
FOR SEXUAL MOLESTATION COVERAGE, PLEASE COMPLETE QUESTIONS 26. THROUGH 30.
$25,000/50,000 limit is included at no additional charge. Higher limits are available for an additional premium charge
(see below). If sexual molestation coverage is not desired, please check here
Coverage is NOT requested.
26.
Has your facility had any incidents or claims brought against it for sexual molestation or any other
allegation of misconduct?
Yes No
Please provide details:
27.
Has any facility that you have been associated with in the past ever had any incidents occur or
claims brought against it while you were there?
Yes No
Describe:
28.
Does your facility do background checks on all employees and volunteers?
Yes No
Describe type of checks performed (prior employer, police, etc.):
29.
Are there written guidelines in place regarding sexual misconduct?
Yes No
If NO, please explain:
30.
Please check the limits you are requesting: $25,000/50,000 - included
$50,000/100,000 $100,000/300,000 $300,000/600,000 $500,000/1MM $1MM/2MM
FOR HIRED AND NON-OWNED AUTO COVERAGE, PLEASE COMPLETE QUESTIONS 31. THROUGH 35.
31.
What types of non-owned autos will be used in your business?
32.
Total Number of Non-owned autos used in your business?
33.
Do you require your employees to have their own insurance?
Yes No
If YES, what are the minimum liability limits required?
34.
Will you use Non-owned autos other than those owned by your employees?
Yes No
If YES, describe relationship and use:
35.
Please check the limits you are requesting:
$100,000 $300,000 $500,000 $1MM
Applicant’s Signature Date
Title Producing Agent
Page 4 of 4 A102 (04/10)
Application For Home Health Care Basic Non-Nursing Services Attachment to A102
Name of Applicant
# Description or Full Details
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Application For Home Health Care Basic Non-Nursing Services (Colonial General Insurance Agency, Inc)

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Completed 22 August 2020

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