Fillable HOME HEALTH CARE & HOSPICE SUPPLEMENTAL APPLICATION (Philadelphia Insurance Companies)

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HOME HEALTH CARE & HOSPICE SUPPLEMENTAL APPLICATION (Philadelphia Insurance Companies)

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HOME HEALTH CARE & HOSPICE SUPPLEMENTAL APPLICATION
Applicant Name:
DBA:
For Profit
Non-Profit
Partnership
Other (specify):
Is the Applicant’s organization more than 25% owned by a private equity fund structure?
Yes
If yes, provide name of private equity firm:
Address:
City:
State:
Zip:
Telephone:
Fax:
Federal Employer Tax I.D. Number:
# of years under present management:
Website address (if available):
Year Established:
Name and Phone number of person to contact for inspection:
Risk Management Contact:
Cell Phone:
Email:
If Applicant has been in business for less than 3 years the following information is required:
• ACORD Application for each line of coverage
• Brochure and/ or Newsletter, if available
• Currently valued losses for the time in business
• Resume of Owner/ Principal
• Client Contract
• Business Plan
• Financial Statement
SECTION I – APPLICANT INFORMATION
1.
Current Coverages (List all coverages, i.e. GL, PL, A&M, Auto, etc.)
Coverages
Insurance
Company
Limit of
Liability
Occurrence or
Claims Made
(if Claims Made
provide
retroactive date)
Deductible
Policy Effective
Dates
Annual
Premium
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
2.
Type of firm (Check all that apply):
Companion care provider
Nurse registry provider
Visiting nurse association
Hospice
Personal care provider
Other:
Infusion therapy provider
Skilled Nursing provider
3.
Total annual gross revenue:
$
4.
Is the Applicant licensed in all state(s) in which it is operating?
Yes
If no, please advise if the state(s) require licensure to operate and /or perform services?
Yes
5.
Is the Applicant Medicare/Medicaid certified and/or licensed?
Yes
6.
Has the Applicant’s license ever been suspended, revoked, voluntarily surrendered or undergone
enforcement action?
Yes
If yes, provide specifics and corrective action taken:
7.
Does common ownership (over 50%) exist with any other operation?
Yes
If yes, give names and types of operations managed and owned: (Provide documentation)
If yes, is coverage desired for operations managed and owned?
Yes
Home Health Care &
Hospice Supplemental
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11/2019
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8.
Does the Applicant contract with a hospital or skilled nursing facility for inpatient beds?
Yes
If yes, please explain:
9.
Types of services provided.
A. Skilled Care Services
Alzheimer’s/ Dementia – Early stages
%
Obstetrical/ doula
%
Alzheimer’s/ Dementia – Advanced stages
%
Occupational Therapy
%
Cardiac care
%
Palliative care
%
Case management
%
Physical Therapy
%
Chemotherapy
%
Radiation therapy
%
Clinical trials
%
Respite care
%
Dialysis
%
Speech therapy
%
Gastronomy (GT) care
%
Trach / Ventilator
%
Hospice services (Complete Section VI)
%
Other (specify):
%
Infusion therapy
%
B. Non-Skilled Services
Companion Care
%
Dietician/ Nutritionist
%
Personal Care
%
Other (specify):
%
C. Miscellaneous Services
Child daycare (Complete Section X)
%
Pharmacy (Complete Section IX)
%
Clergy
%
Supplemental staffing – Non Medical
(Complete Section VIII)
%
Consumer Directed Personal Assistance
Program Intermediary
%
Supplemental staffing – Medical
(Complete Section VIII)
%
Handyman
%
Meals on Wheels
%
Training/ Certification
%
Medical Equipment Supplier
(Complete Section VII)
%
Telehealth
%
Thrift shops
%
Pet therapy
%
Wet nurse
%
Other (specify):
%
Other (specify):
%
TOTAL % of A, B, & C (Should equal 100%)
%
10.
Provide the number of clients served by age.
Age of Clients
Annual Number of Clients
0 – 5
6 - 18
19 - 65
Over 65
a.
What percentage of pediatric clients are medically fragile (i.e. feeding tube, breathing tube, ventilator)
11.
What percentage of the overall services are live-in? %
*Live-in care is considered to be greater than 48 hours of continuous care provided by the same caregiver.
12.
Location(s) of Services Provided (Total must equal 100%)
Adult day care facilities
%
Owned facility
%
Assisted living facilities
%
Prisons/ Correctional Facilities
%
Hospitals
%
Private homes
%
Nursing homes
%
Schools
%
Other:
%
TOTAL
%
13.
With respect to the coverages applied for, has any company refused, cancelled, or non-renewed
coverage (Not applicable in Missouri)
Yes
14.
Describe any changes in operations planned within the next year:
N/A
Home Health Care &
Hospice Supplemental
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15.
Is the Applicant accredited or a member of the following health care organizations:
a.
Community Health Accreditation Program (CHAP)?
Yes
b.
Joint Commission on Accreditation of Health Care Organizations (JCAHO)?
Yes
c.
Accreditation Commission for Health Care (ACHC)?
Yes
d.
Any other accrediting organization (please specify)?
16.
Annual Staffing – Employees & Independent Contractors
Total number of:
Employees:
Independent Contactors:
Volunteers:
Staffing
Total #
of
Annual
Hours
Worked
Total # of
Employees
Total # of
Independent
Contractors
Annual Payroll
(Or 1099 Amount)
FT PT FT PT Employees
Independent
Contractors
Case Managers
Certified Nursing Assistants
Companion/homemakers
Counselors
Dentists*
Licensed Social Workers
LPN’s
Medical Directors (Admin Only)
Nurse Practitioners
Nutritionists
Occupational Therapists
Opticians*
Optometrists/Ophthalmologist
Paramedic EMTs
Pediatricians*
Personal Care Attendants
Pharmacists
Physicians*
Physicians Assistants
Physicians Hospice*
Physical Therapists*
Psychiatrists*
Psychologists
Resident Managers
RN’s
Social Workers
Speech Therapists
*Other (describe):
*Other (describe):
F/T = Full Time – over 20 hours per week / P/T = Part Time – up to 20 hours per week
*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.
*Complete the following chart if Vicarious medical professional coverage is desired for professional services rendered
on the Applicant’s behalf by the above noted employed or volunteer Physicians, Psychiatrists, Dentists or Opticians
who carry their own primary medical professional insurance:
Professional’s Name
Medical Specialty
Medical License #
Primary Ins. Carrier
Primary Limits
Home Health Care &
Hospice Supplemental
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SECTION II - HIRING / SCREENING
1.
Check all methods used in the hiring/ screening process:
Hiring/ Screening Processes
Employee
Contractors
Volunteers
Drug & Alcohol testing – At time of Hire
Drug & Alcohol testing - Randomly
Criminal background checks – Federal
Criminal background checks – State
Reference checks - Written
Reference checks - Verbal
Personal interview
Sexual abuse registry
Validate work history
Validate education
Verify current certification/ Professional license
Validate driver’s license
Validate personal auto insurance and limits
(If operating owned vehicle during company Hours)
2.
What is the average staff turnover rate: %
3.
Are job descriptions provided for all professional and non-professional employees?
Yes
No
4.
Does the Applicant question prospective employees and/or independent contractors about ever
having their license revoked or suspended, any disciplinary action taking against them or being a
defendant in professional litigation?
Yes
No
If no, please explain what verification procedures are in place:
5.
Are independent contractors required to carry their own individual professional liability coverage?
Yes
No
Limits of Liability: $
6.
Describe any additional pre-employment screening and assessments procedures?
SECTION III - RISK MANAGEMENT – QUALITY CONTROL
1.
Is the overall responsibility for Risk Management assigned to one individual in your organization?
Yes
No
If no, how are the risk management functions monitored?
2.
Describe what formal documented training is in place:
3.
What is the average training provided to newly hired staff:
>5 Hours
1 – 5 Hours
No training is provided
4.
What is the average ongoing training provided to their staff:
>8 Hours
1 – 7 Hours
No ongoing training is provided
5.
Does the Applicant provide training to all employees on how to properly transfer clients?
Yes
No
6.
Does the Applicant have formal HIPAA compliance procedures in place?
Yes
No
7.
Does the Applicant have a formal incident report procedure in place?
Yes
No
Home Health Care &
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8.
Does the Applicant have developed written protocols that govern the admission and medical
treatment of patients for the following policies and procedures:
a.
Copy of literature given to clients explaining services and fees?
Yes
No
b.
Complete treatment plan prescribed by the physician, including follow up plans?
Yes
No
c.
Medications and dosage, including documentation of administering medications?
Yes
No
d.
Complete medical records maintained on all patients?
Yes
No
If yes, are records kept on file (hardcopy or electronic) for a minimum of 6 years?
Yes
No
e.
Standard client contracts and “informed consent” documents obtained and placed in the
patient’s medical record?
Yes
No
If yes, please attach a copy of standard client contract.
f.
Documentation of all homecare training?
Yes
No
g.
Meticulous documentation of all patient care and home visits?
Yes
No
h.
Changes in the condition of a patient or incidents involving the patient documented in the
records and reported to the family and physician?
Yes
No
i.
Termination of services and discharge of criteria?
Yes
No
9.
Does the Applicant have current contracts with pharmacies, durable medical equipment suppliers,
hospitals, nursing home and/or assisted living homes in place?
Yes
No
If yes, is there a review process requiring the following elements: (**Please attach copy of all agreements.**)
Hold harmless and indemnification
clauses favorable to the applicant?
Yes
No
Terms and renewal conditions clearly
outlined?
Yes
No
Insurance requirements?
Yes
No
Termination clause?
Yes
No
Confidentially clause?
Yes
No
Defined roles and responsibility?
Yes
No
10.
Does the Applicant require employees and independent contractors to complete daily work
reports?
Yes
No
11.
Does the Applicant conduct patient/ client surveys?
Yes
No
If yes, are the results to improve day-to-day operations?
Yes
No
SECTION IV – ABUSE AND MOLESTATION
1.
Does the Applicant’s organization have a written “zero tolerance” sexual and physical abuse
molestation policy?
Yes
No
If yes:
a.
Does the Applicant’s written policy include: (Please provide a copy)
Definition of sexual and
physical abuse/molestation?
Yes
No
Investigation procedures?
Yes
No
Disciplinary procedures?
Yes
No
Incident reporting procedures
Yes
No
Retaliation warning?
Yes
No
b.
Is the policy consistently enforced, requiring annual review by each employee and/or
volunteer, mandating individual signoff that he or she has read the policy, has received
appropriate training and agrees to adhere to the policy?
Yes
No
c.
Have procedures been established to monitor the implementation of the program?
Yes
No
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 they have an incident of abuse?
Yes
No
4.
Are there written procedures that monitors staff in day-to-day relationships with clients, both on and
off premises?
Yes
No
5.
Is there formal staff training on sexual abuse, including how to recognize the signs?
Yes
No
6.
Is there more than one person responsible for the welfare of any single live-in patient?
N/A
Yes
No
7.
Will any independent contractors have access to children or perform operations where they will be
physically touching another person?
Yes
No
If yes, please explain:
Home Health Care &
Hospice Supplemental
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8.
Have any incidents resulted in an allegation of sexual or physical abuse?
Yes
No
If yes, please explain:
SECTION V - AUTOMOBILE
1.
Are there any company-owned vehicles?
Yes
No
**Please note that we will not write the non-owned auto without the scheduled vehicles.
If yes:
a.
Does the Applicant allow personal use of a company-owned vehicle?
Yes
No
b.
Is there a formal, written Fleet Safety Program in place?
Yes
No
c.
Are family members allowed to use the company owned vehicles?
Yes
No
d.
Does the Applicant allow any newly hired drivers to operate vehicles without going through a
company specific documented driving training?
Yes
No
2.
Does the Applicant contract with an ambulance or livery service to transport clients?
Yes
No
(If yes, please provide a copy of the contract)
3.
Does the Applicant make sure travel logs are kept for all drivers?
Yes
No
4.
How often does the Applicant check MVR reports?
Never
At time of hire only
Annually
Randomly
5.
Does the Applicant have a formal driving policy in place with MVR standards?
Yes
No
If yes:
a.
Is driving policy communicated in writing to all employees?
Yes
No
b.
Is a signed acknowledgement form kept on file?
Yes
No
If yes, please provide a copy of signed acknowledgement.
c.
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
6.
Are all drivers at least twenty-one (21) years of age?
Yes
No
7.
Are all drivers trained on wheelchair securement protocols & procedures?
Yes
No
8.
Number of Applicant’s staff who use their personal vehicles within the scope of business:
Employees:
Volunteers:
Independent Contractors:
a.
Total annual miles driven by staff:
9.
Does the Applicant allow staff to transport clients?
Yes
No
If yes:
a.
How often is transportation provided?
b.
How many of the Applicant’s staff aged between twenty-one (21) to twenty-five (25) transport
clients?
c.
Are any clients non-ambulatory?
Yes
No
10.
Does the Applicant obtain certificates of insurance or a copy of the declarations page from the
caregiver’s personal insurer?
Yes
No
If yes, who maintains these records?
11.
Does the Applicant confirm all drivers personal auto policies do not exclude claims arising out of
the course of driving if part of their profession?
Yes
No
12.
Does the Applicant require caregivers to carry personal auto insurance with limits of at least
$100,000?
Yes
No
13.
Does the Applicant require independent contractors to list the Applicant as an additional insured?
Yes
No
14.
Does the Applicant allow their caregivers to operate client vehicles?
Yes
No
If yes:
a.
How does the Applicant verify patient and/or client owned automobile liability coverage is in
force?
b.
Does the Applicant require evidence of regular preventative maintenance?
Yes
No
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Hospice Supplemental
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SECTION VI - HOSPICE
N/A
1.
Describe the Applicant’s Hospice Model (Please check all that apply):
Freestanding:
A hospice inpatient facility that is administratively and physically freestanding. This
type of hospice operates a home care program for the inpatient.
Hospital-Based:
A hospice administratively or physically linked to a hospital. This type of hospice
operates a home care program and may also operate an inpatient unit.
Nursing Home
Based:
A hospice administratively or physically linked to a nursing home or long-term care
facility. This type of hospice operates a home care program and an inpatient unit.
Community-Based:
A hospice home care program that operates under an autonomous administration.
This type of hospice may be affiliated with an inpatient unit.
Home Health
Agency Based:
A hospice administratively or physically linked to a Hospital-Based or Home-Health
Agency. This type of hospice may contract for inpatient services.
2.
Describe the Applicant’s Hospice “Type” (please check all that apply):
Routine Home Care
As long as the patient’s symptoms are under control, the hospice team supports
the caregivers in providing this level of care in the home setting, whether that is a
private residence, assisted living or nursing home.
# of patients for type of service (12 months’ time):
# of visits for type of service (12 months’ time):
Crisis Care
In the event of a medical or psychosocial crisis, 24-hour care can be provided in
the home for brief periods.
# of patients for type of service (12 months’ time):
# of visits for type of service (12 months’ time):
Inpatient Respite
Care
Caregivers occasionally need to take short breaks to maintain their own health. In
this instance, the patient can be transferred to a short-term (up to five days) care
unit while the caregiver takes a break. Respite care is provided in a nursing home
setting.
# of patients for type of service (12 months’ time):
# of visits for type of service (12 months’ time):
General Inpatient
Care
When symptoms can’t be controlled in a home setting, this level of care may be
provided in many hospitals or the patient can be moved to an Inpatient Center for a
short-term stay until pain and symptoms are under control.
This level of care is also offered in select nursing homes. Patients residing in such
nursing homes may be moved to an inpatient bed within the same facility. In all
other nursing homes, patients may be moved to an Inpatient Center or to a nearby
hospital.
# of patients for type of service (12 months’ time):
# of visits for type of service (12 months’ time):
3.
Please provide the percentage of the age of Hospice clients served:
Client
Percentage
Client
Percentage
Children/ Teenagers (1-17)
%
Adults (22-64)
%
Young Adults (18-21)
%
Geriatric (over 65)
%
4.
Are medications kept in a locked area to prevent tampering?
Yes
No
5.
Describe the organization’s policy for disposal of controlled substances:
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SECTION VII – MEDICAL SUPPLIES
N/A
1.
Does the Applicant manufacture any products?
Yes
No
If yes, please describe:
2.
Does the Applicant provide any durable medical equipment to clients?
Yes
No
If yes, please describe:
3.
Does the Applicant sell any medical supplies or equipment?
Yes
No
If yes, please describe:
Total annual sales: $
4.
Does the Applicant rent or lease any medical supplies or equipment to others?
Yes
No
Total rental or leasing sales: $
5.
Does the Applicant repair or perform maintenance on any medical supplies or equipment?
Yes
No
6.
Is the Applicant named as an Additional Insured – Vendor on the manufacturer or supplier’s policy
for any products?
Yes
No
7.
Does the Applicant obtain certificates of insurance from their product suppliers?
Yes
No
8.
Has the Applicant ever distributed or directly imported products from a foreign manufacturer?
Yes
No
9.
Does the Applicant modify any product in any way from its intended use?
Yes
No
If yes, please explain:
10.
Does the Applicant repackage or re-label any items obtained from suppliers?
Yes
No
11.
Do manufacturer’s labels remain on the equipment?
Yes
No
12.
Are serial numbers of the finished product shown on invoices and complete records of
inventory kept?
Yes
No
13.
Products Offered (Percentages must equal 100%)
Product/ Service
Product/ Service
Apnea monitors
%
Parental Therapy
%
Apnea monitors – infant
%
Pharmacy sales
%
Auto conversions / modifications
%
Photo therapy equipment - infants
%
Bed, commodes
%
Scooters
%
Blood cleansing or recirculation equipment
%
Safety bar/ Grab bar installation
%
Chemotherapy
%
Safety bar/ Grab bar sales
%
CPAP/ BIBPAP
%
Sleep apnea studies
%
CPM
%
Stair lift – installation
%
Diabetic shoes
%
Stair lift – sales
%
Enteral Therapy
%
Ten units
%
Infant beds or cribs
%
Ventilators
Does the Applicant instruct on the use of
ventilators?
%
Liquid oxygen
%
Yes
No
Medical gas piping
%
Nebulizers
%
Walkers, crutches, canes
%
Orthotics & prosthetic sales or fitting
%
Wheel chair – motorized
%
Oxygen concentrators
%
Wheel chair – manual
%
Oxygen cylinders
%
Other:
%
Oxygen regulators and values
%
Other:
%
ABOVE MUST TOTAL 100%:
%
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SECTION VIII- SUPPLEMENTAL STAFFING
N/A
1.
If the Applicant provides any supplemental staffing services please advise:
a.
Total revenues derived from supplemental staffing services: $
b.
Percentage of total revenues by location of staffing services (total must equal 100%)
Adult day care facilities
%
Nursing home/Assisted or Independent Living
facilities
%
Clinics
%
Doctors offices
%
Prison facilities
%
Hospices
%
Schools
%
Hospitals
%
Other (specify):
%
Laboratories
%
Total:
%
2.
If Supplemental Staffing is provided to Hospitals, please specify percent of total revenues by
specialized service (total must equal 100%)
Coronary care unit
%
Obstetrical
%
Emergency department
%
Pediatric
%
Intensive care unit
%
Psychiatric
%
Medical/ Surgical unit
%
All other units (specify):
%
Neonatal
%
Total:
%
3.
Do contractual agreements to provide temporary or supplemental staffing to client facilities include
the following provisions:
a.
Mutual indemnification and hold harmless agreements?
Yes
No
b.
Require third parties to carry liability insurance with limits of at least $1M/ $3M?
Yes
No
c.
Please provide a copy of the Applicant’s standard contract.
SECTION IX - PHARMACY
N/A
1.
If Applicant owns or operates a pharmacy what are the total receipts from:
a.
Retail pharmacy
$
b.
Closed pharmacy
$
c.
Mail/Online Orders
$
d.
Does the pharmacy compound medications?
Yes
No
e.
Does the pharmacy dispense controlled narcotics?
Yes
No
f.
Does the pharmacy provide medications to other organizations?
Yes
No
If yes, please describe:
SECTION X – CHILDCARE/ DAYCARE
N/A
1.
What is the total number of individuals providing childcare/ nanny care/ day care:
Employees:
Independent Contractors:
Volunteers:
Are the above individuals included in question #18 of Section 1 and the payroll figures?
Yes
No
2.
Please provide the number of child care / nanny care / day care visits the Applicant makes in a month:
3.
Does the Applicant provide transportation of children?
Yes
No
If yes, how many trips and average miles per month?
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Hospice Supplemental
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SECTION XI – WARRANTY STATEMENT
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 process 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 them?
Yes
No
If yes, please provide details:
2.
Upon inquiry of any 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 for?
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 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)
Home Health Care &
Hospice Supplemental
Page 11 of 11
© 2019 Philadelphia Consolidated Holding Corp.
11/2019
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HOME HEALTH CARE & HOSPICE SUPPLEMENTAL APPLICATION (Philadelphia Insurance Companies)

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Completed 29 July 2020

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