Fill - Free fillable HOME HEALTH CARE AND HOSPICE RENEWAL SUPPLEMENTAL APPLICATION (Philadelphia Insurance Companies) PDF form

HOME HEALTH CARE AND HOSPICE RENEWAL

SUPPLEMENTAL APPLICATION

Applicant Name:

SUBMISSION REQUIREMENTS

• PHLY Home Health Care Renewal Supplemental Application

• Copy of State(s) Home Health Care License(s) and most recent State Licensure survey

• Copy of all Federal and State complaint investigation reports in the last twelve (12) months

• (If contracted with Nursing Homes, Assisted Living and Hospitals); Provide copies of any new Indemnification

Agreement, Hold Harmless Agreement, Additional Insured Provisions

• Physician’s Application required for each insured physician

APPLICANT INFORMATION

1. Total Annual Gross Receipts: $ Total receipts from Medicaid: $

Total receipts from Medicare: $ Total receipts from Private Pay: $

2. Describe any changes in operations during the last year:

4. How many drivers use personal vehicles for business?

5. Types of services provided:

Skilled Care Services

Cardiac care % Dietician / Nutritionist %

Case management % Gastronomy (GT) care %

Chemotherapy % Hospice services %

Clinical trials % Palliative care %

Dialysis % Respite care %

Infusion therapy % Special care (Alzheimer’s / Dementia) %

Obstetrical /doula % Trach / Ventilator %

Radiation therapy % Other (specify): %

Rehabilitation: Physical, Occupational,

Speech therapy

Total Skilled Care Services

Non-Skilled Services

Companion / Sitter / Personal Care % Mid-Wife %

Dietician / Nutritionist % Palliative care %

Gastronomy (GT) care % Respite care %

Hospice % Other (specify): %

Total Non-Skilled Services %

Miscellaneous Services

Child daycare % Pharmacy %

Clergy % Social services %

Consumer Directed Personal Assistance

Program Intermediary

Supplemental staffing %

Training/Certification %

Handyman % Telehealth %

Meals on Wheels % Thrift shops %

Medical equipment supplier % Wet nurse %

Pet therapy % Other (specify): %

Supplemental Services (Supplying health care providers to other facilities for a fee): IF “NO” check here:

Private Homes

Hospitals %

Clinics %

Doctor’s Offices % Nursing Homes % Owned Facility %

Assisted Living Facilities % Other: % Other: %

Above must total 100%

3. Yes No Is the Applicant’s organization more than 25% owned by a private equity fund structure?

If yes, provide name of private equity firm:

Home Health Care and

Hospical Renewal Supplemental

Page 1 of 6

10/2018

Print Application

Clear ApplicationClear Application

Print Application

Does Applicant provide advanced skilled care (i.e. ventilator, chemotherapy, radiation therapy etc.)? Yes No

If yes, what are the clinical expertise requirements and/or professional training for staff that will

provide these services?

8. Does the Applicant provide pediatric care? Yes No

If “yes” what is the percentage of total patients: %

If yes, describe the types of pediatric services provided:

Are any of the patients deemed medically fragile (i.e.: feeding tube, breathing ventilator)? Yes No

9. Does the Applicant provide live-in Home Health Care Service? Yes No

If yes, what is the percentage? %

Location of Services Provided (total must equal100%)

Adult day care facilities % Laboratories % Private homes %

Assisted living facilities % Nursing homes % Schools %

Clinics % Outpatient facilities % Other: %

Doctor’s offices % Owned facility %

Total:

Hospitals % Prisons %

11. Describe any changes in operations planned within the next year: N/A

10.

Home Health Care and

Hospical Renewal Supplemental

Page 2 of 6

10/2018

12. Professional Liability Employees / Independent Contractors – Annual Staffing:

Total number of: Employees: Independent Contractors: Volunteers:

Staffing

Total #

Annual

Hours

Worked

Total # of

Employees

Total # of

Independent

Contractors

Total # of

Volunteers

Annual Payroll

(Or 1099 Amount)

FT PT FT PT Employees

Independent

Contractors

Counselors

Social Workers

Occupational Therapists

Speech Therapists

Teachers

Nutritionists

Resident Managers

Home Health Aides

Licensed Social Workers

Sociologists

RN’s

LPN’s

Physical Therapists

Psychiatrists

Physicians Hospice

Pediatricians

Physicians

Dentists

Opticians

Psychologists

Medical Directors (Admin. Only)

Nurse Practitioners

Physicians Assistants

Pharmacists

Paramedic EMTs

*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.

Optometrists/Ophthalmologist

Print Application

Clear ApplicationClear Application

Print Application

13.

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.

If the Physician, Psychiatrist, Dentist or Optician currently has medical professional coverage with the

company, the Applicant will not need to submit a newly completed medical professional application.

Please confirm names of medical professionals that are currently insured with company.

Name Specialty

14.

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.

15. 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

16. Please advise if the Applicant’s hospice model (i.e. freestanding, hospital-based, home health care

agency based) has changed in the last 12 months or is expected to change in the coming 12

months

Yes No

17. Please advise if the Applicant’s hospice type (i.e. routing home care, crisis care, inpatient respite

care, general inpatient care) has changed in the last 12 months or is expected to change in the

coming 12 months?

Yes No

AUTOMOBILE

1. Yes No Does the Applicant have a formal driving policy in place with MVR standards?

If yes:

a. How often does the Applicant check MVR reports?

b. Is driving policy communicated in writing to all employees? Yes No

c. Yes No Is a signed acknowledgement form kept on file?

If yes, please provide a copy.

d. Do driving standards include the following:

i. No major violations including DUI, racing, hit and run, speeding in excess of 20 mph over

posted speed limit, manslaughter? Yes No

ii. No more than 2 moving violations within past 3 years? Yes No

iii. No more than 1 at fault accident within past 3 years? Yes No

2. Yes No Does the Applicant allow employees to drive personal vehicles for company purposes?

If yes:

a. How many drivers use personal vehicles for business?

b. Are the driving policy and standard for these drivers the same as in questions 1? Yes No

Yes No

Does the Applicant require all homecare providers who use their own vehicles for company

business to carry personal auto insurance?

If yes, what limits are required? $

Home Health Care and

Hospical Renewal Supplemental

Page 3 of 6

10/2018

Print Application

Clear 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

SECTION TO BE COMPLETED BY THE PRO

DUCER/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)

Home Health Care and

Hospical Renewal Supplemental

Page 4 of 6

10/2018

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 against

the Applicant alleg

ing 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