Fillable HALFWAY HOUSE GENERAL LIABILITY APPLICATION (Colonial General Insurance Agency, Inc)

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HALFWAY HOUSE GENERAL LIABILITY APPLICATION (Colonial General Insurance Agency, Inc)

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GLS-APP-41s (9-16) Page 1 of 7
Scottsdale Insurance Company
Home Office: One Nationwide Plaza
Columbus, Ohio 43215
Adm. Office: 8877 North Gainey Center Drive
Scottsdale, Arizona 85258
Scottsdale Indemnity Company
Home Office: One Nationwide Plaza
Columbus, Ohio 43215
Adm. Office: 8877 North Gainey Center Drive
Scottsdale, Arizona 85258
Scottsdale Surplus Lines Insurance Company
Adm. Office: 8877 North Gainey Center Drive
Scottsdale, Arizona 85258
HALFWAY HOUSE GENERAL LIABILITY APPLICATION
Applicant’s Name:
Mailing Address:
Location Address:
Agency Name:
Agent No.:
Address:
E-mail:
Phone No.:
PROPOSED EFFECTIVE DATE: From To 12:01 A.M., Standard Time at the address of the Applicant
ANSWER ALL QUESTIONS—IF THEY DO NOT APPLY, INDICATE “NOT APPLICABLE” (N/A)
Applicant is: Individual Corporation Partnership Joint Venture Limited Liability Company
Other (Specify):
Website Address:
E-mail Address: Phone No.:
Limits Of Liability and Deductible Requested:
General Aggregate (other than Products/Completed Operations)
$
Products and Completed Operations Aggregate $
Personal and Advertising Injury (any one person or organization) $
Each Occurrence $
Damage To Premises Rented To You (any one premise) $
Medical Expense (any one person) $
Errors and Omissions Coverage Each Claim
(Limits must be equal to General Liability limits) Aggregate
$
$
Sexual and/or Physical Abuse Coverage
$ 25,000/$ 50,000 (included)
$ 50,000/$100,000
$100,000/$300,000
Other Coverages, Restrictions and/or Endorsements:
$
Deductible $
GLS-APP-41s (9-16) Page 2 of 7
1. Applicant operates as: Profit Nonprofit Number of years in operation:
2. How long under present management? (If fewer than five years, attach principals’ resumes. If
principals in the firm do not have a health care background, then also include the resume of the individual responsible
for hiring, screening and monitoring the work activities of employees.)
3. Is facility owned by physician(s)? ........................................................................................................... Yes No
If yes, is physician(s) involved in day-to-day operations? ........................................................................... Yes No
4. Type of operation:
Birth control, pregnancy or abortion counseling/clinic Mission or settlement house
Blood testing or communicable disease clinic Non-medical drug and alcohol rehabilitation center
Crises center (rape, domestic violence, etc.) Outpatient aftercare and support program (AA,
Food bank Al-Anon, etc.)
Halfway house Outpatient counseling or guidance center
Healthcare clinic Prisoners work release or rehabilitation program
Homeless shelter Psychiatric institution
Hospice facility Soup kitchen
Medical urgent care facility Youth hostel
Describe type of operation and services provided (attach brochure and/or advertising material if available):
5. Does applicant provide any off-premises services? ............................................................................. Yes No
If yes, advise:
6. Any previous or pending allegations of sexual and/or physical abuse? ............................................ Yes No
7. Total number of employees: .....................................................................................................................
8. As part of hiring/screening of new employees, does applicant:
a. Obtain copies of their professional licenses/certifications? .................................................................. Yes No
b. Contact applicants’ references before they are hired? ......................................................................... Yes No
c. Require that they carry their own professional liability policy? ............................................................. Yes No
9. Operations conducted in the following states:
State: Licensed with state? ............ Yes No License No.:
State: Licensed with state? ............ Yes No License No.:
State: Licensed with state? ............ Yes No License No.:
10. Has license ever been revoked? .............................................................................................................. Yes No
If yes, explain:
11. Name all subsidiary companies/locations and others coming under applicant’s control: (if none, please state)
12. Has applicant sold, acquired or discontinued any operations in the last five years? ....................... Yes No
If yes, explain:
13. Is at least one of the principals or an Administrator/Director involved in the operation on a full-
time basis? .................................................................................................................................................
Yes No
GLS-APP-41s (9-16) Page 3 of 7
14. Physical features of risk:
a. Year built: ..............................................................................................................................................
b. Construction of building:
c. Number of floors: On which floor(s) is applicant located?
Square foot area occupied by applicant:
d. Equipped with sprinkler system? .......................................................................................................... Yes No
Equipped with fire alarm? ...................................................................................................................... Yes No
If yes: ...................................................................................................................... Central station Local alarm
Equipped with smoke detectors? .......................................................................................................... Yes No
If yes, how many on each floor? ...........................................................................................................
e. Number of fire extinguishers on premises: Number of fire escapes:
f. Is smoking allowed on premises? ......................................................................................................... Yes No
If yes, where is it permitted?
g. Is there a swimming pool or hot tub/spa on premises? ........................................................................ Yes No
If yes:
• Number of pools: ............................................................................................................................
• Are the pools fully fenced with self-latching gates? ........................................................................ Yes No
• Are the rules posted? ..................................................................................................................... Yes No
• Is there life-safety equipment at poolside? ..................................................................................... Yes No
• Is there a diving board, platform or slide? ...................................................................................... Yes No
If yes, height of each:
• Are all swimming pools, wading pools, hot tubs and spas in compliance with the federal Virgin-
ia Graeme Baker Pool and Spa Safety Act? ..................................................................................
Yes No
h. Was building originally built for this type of occupancy? ....................................................................... Yes No
15. Evacuation procedures:
a. Does applicant have a written Emergency Evacuation Plan? .............................................................. Yes No
b. Does evacuation plan include advance agreement for transportation and temporary shelter? ........... Yes No
c. Are evacuation procedures posted in all parts of the facility? ............................................................... Yes No
If yes, are posted evacuation procedures bilingual? ............................................................................. Yes No
d. How often are drills conducted?
16. State patients’/residents’ ages: Youngest: Oldest: Average age:
17. Physicians on premises, if any, are:
Private practitioners (personal physicians of the residents)
Employees of applicant
Contracted physicians through written contract with applicant
If contracted physician, are certificates/evidence of professional liability insurance required and
kept on file? ...........................................................................................................................................
Yes No
18. Do services provided include?
Infusion therapy? ......................................................................................................................................... Yes No
Dialysis? ...................................................................................................................................................... Yes No
Physical therapy? ........................................................................................................................................ Yes No
Does treatment process involve the administration of methadone or other drugs? .................................... Yes No
19. Are employees authorized to use their personal vehicles to transport residents or patients? ........ Yes No
GLS-APP-41s (9-16) Page 4 of 7
20. Are residents/patients placed in applicant’s facility by court order? .................................................. Yes No
21. Any involvement in medical detoxification? .......................................................................................... Yes No
22. Does facility accept prisoners? ............................................................................................................... Yes No
23. Does facility accept teens with a past history of violence or attempted suicide? ............................. Yes No
24. Does facility provide pregnancy and/or abortion counseling services? ............................................. Yes No
25. Does facility, if an inpatient facility, accept children under the age of eighteen (18)? ...................... Yes No
If yes, does applicant also require the child’s guardian to be in residence at the same facility? ................ Yes No
26. Is facility a foster home or foster care facility? ...................................................................................... Yes No
27. Does facility provide inpatient services or permanent housing for either of the following:
a. Developmentally Disabled—Adults or children able to care for themselves despite their disability
or mental retardation. Examples of this category include Down Syndrome, autism and brain inju-
ries. This category does not include individuals whose primary diagnosis is an emotional or mental
illness. ...................................................................................................................................................
Yes No
b. Mentally Disabled—Adults or children able to care for themselves (with substantial numbers able
to hold jobs). Behavior is controlled through medication and monitored by their personal physician.
This category would include individuals whose primary diagnosis is an emotional or mental illness
including, but not limited to, schizophrenia, psychopathic and sociopathic diagnosis. ........................
Yes No
28. Does applicant provide bed and board facilities? ................................................................................. Yes No
If yes, number of beds: ................................................................................................................................
Length of stay: From (shortest): To (longest): Average:
29. Does applicant provide outpatient services? ......................................................................................... Yes No
If yes, number of annual outpatient visits: ...................................................................................................
30. Explain arrangement for medical emergencies (i.e., M.D. on call, transfer arrangements with hospital, etc.):
31. Does applicant have Workers’ Compensation coverage in force? ...................................................... Yes No
32. Does applicant have any contractual agreements wherein applicant assumes the liability of
others? ........................................................................................................................................................
Yes No
If yes, attach a list of each entity that has requested to be named as an additional insured and the type of service(s)
applicant provides.
33. Any other premises or operations exposures not stated in this application? ................................... Yes No
If yes, attach a complete description and underwriting/rating information.
34. During the past five years, have any claims been made or suits brought against the applicant
because of alleged malpractice, error, mistake or premises accident arising in any manner out
of applicant’s operation? ..........................................................................................................................
Yes No
If yes, advise date and details:
35. Additional Insured Information:
Name Address Interest
GLS-APP-41s (9-16) Page 5 of 7
36. During the past three years, has any company canceled, declined or refused similar insurance
to the applicant? (Not applicable in Missouri) ...........................................................................................
Yes No
If yes, explain:
37. Does risk engage in the generation of power, other than emergency back-up power, for their
own use or sale to power companies?....................................................................................................
Yes No
If yes, describe:
38. Does applicant have other business ventures for which coverage is not requested? ...................... Yes No
If yes, explain and advise where insured:
39. Schedule of Hazards:
Loc.
No.
Classification Description
Class.
Code
Exposure
Premium Basis
(s) Gross Sales
(p) Payroll
(a) Area
(c) Total Cost
(t) Other
40. Prior Carrier Information:
Year:
Year:
Year:
Year:
Year:
Carrier
Policy Number
Coverage
Occurrence or
Claims Made
Total Premium $
$
$
$
$
41. Loss History:
Indicate all claims or losses (regardless of fault and whether or not insured) or occurrences that may give
rise to claims for the prior five years.
Check if no losses last five
years.
Date of
Loss
Description of Loss
Amount
Paid
Amount
Reserved
Claim Status
(Open or
Closed)
$
$
$
$
$
$
$
$
$
$
GLS-APP-41s (9-16) Page 6 of 7
This application does not bind the applicant nor the Company to complete the insurance, but it is agreed that the infor-
mation contained herein shall be the basis of the contract should a policy be issued.
FRAUD WARNING: 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. (Not applicable in AL, CO, DC, FL, KS, LA, ME, MD, MN, NE, NY,
OH, OK, OR, RI, TN, VA, VT or WA.)
NOTICE TO ALABAMA APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a
loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be
subject to restitution fines or confinement in prison, or any combination thereof.
NOTICE TO COLORADO APPLICANTS: It is unlawful to knowingly provide false, incomplete, or misleading facts or in-
formation 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 policy holder or claimant for
the purpose of defrauding or attempting to defraud the policy holder or claimant with regard to a settlement or award pay-
able from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory
Agencies.
WARNING TO DISTRICT OF COLUMBIA APPLICANTS: It is a crime to provide false or misleading information to an
insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addi-
tion, an insurer may deny insurance benefits if false information materially related to a claim was provided by the appli-
cant.
NOTICE TO FLORIDA APPLICANTS: Any person who knowingly and with intent to injure, defraud, or deceive any insur-
er files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a fel-
ony of the third degree.
NOTICE TO KANSAS APPLICANTS: Any person who, knowingly and with intent to defraud, presents, causes to be pre-
sented 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 state-
ment 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 con-
ceals, 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.
NOTICE TO LOUISIANA APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a
loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be sub-
ject to fines and confinement in prison.
NOTICE TO MAINE APPLICANTS: 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.
NOTICE TO MARYLAND APPLICANTS: Any person who knowingly or willfully presents a false or fraudulent claim for
payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty
of a crime and may be subject to fines and confinement in prison.
NOTICE TO MINNESOTA APPLICANTS: A person who files a claim with intent to defraud or helps commit a fraud
against an insurer is guilty of a crime.
NOTICE TO OHIO APPLICANTS: Any person who, with intent to defraud or knowing that he is facilitating a fraud against
an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.
NOTICE TO OKLAHOMA APPLICANTS: Any person who knowingly, and with intent to injure, defraud or deceive any
insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading infor-
mation is guilty of a felony.
GLS-APP-41s (9-16) Page 7 of 7
NOTICE TO RHODE ISLAND APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment
of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be
subject to fines and confinement in prison.
FRAUD WARNING (APPLICABLE IN VERMONT, NEBRASKA AND OREGON): Any person who intentionally presents
a materially false statement in an application for insurance may be guilty of a criminal offense and subject to penalties un-
der state law.
FRAUD WARNING (APPLICABLE IN 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. Penal-
ties include imprisonment, fines, and denial of insurance benefits.
NEW YORK AUTOMOBILE FRAUD WARNING: Any person who knowingly and with intent to defraud any insurance
company or other person files an application for commercial insurance or a statement of claim for any commercial or per-
sonal insurance benefits containing any materially false information, or conceals for the purpose of misleading, infor-
mation concerning any fact material thereto, and any person who, in connection with such application or claim, knowingly
makes or knowingly assists, abets, solicits or conspires with another to make a false report of the theft, destruction, dam-
age or conversion of any motor vehicle to a law enforcement agency, the department of motor vehicles or an insurance
company, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed
five thousand dollars and the value of the subject motor vehicle or stated claim for each violation.
NEW YORK OTHER THAN AUTOMOBILE FRAUD WARNING: 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 also be subject to a civil penalty not to exceed five thousand dollars
and the stated value of the claim for each such violation.
APPLICANT’S STATEMENT:
I have read the above application and I declare that to the best of my knowledge and belief all of the foregoing statements
are true, and that these statements are offered as an inducement to us to issue the policy for which I am applying. (Kan-
sas: This does not constitute a warranty.)
APPLICANT’S SIGNATURE: DATE:
CO-APPLICANT’S SIGNATURE: DATE:
PRODUCER’S SIGNATURE: DATE:
AGENT NAME: AGENT LICENSE NUMBER:
(Applicable to Florida Agents Only)
IOWA LICENSED AGENT:
(Applicable in Iowa Only)
IMPORTANT NOTICE
As part of our underwriting procedure, a routine inquiry may be made to obtain applicable information concerning
character, general reputation, personal characteristics and mode of living. Upon written request, additional
information as to the nature and scope of the report, if one is made, will be provided.
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HALFWAY HOUSE GENERAL LIABILITY APPLICATION (Colonial General Insurance Agency, Inc)

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Completed 22 August 2020

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