Fillable HOME HEALTHCARE APPLICATION (RT Specialty)

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HOME HEALTHCARE APPLICATION (RT Specialty)

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The HOME HEALTHCARE APPLICATION (RT Specialty) form is 6 pages long and contains:

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  • 3 check-boxes
  • 332 other fields

Country of origin: US
File type: PDF

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Page 1 of 6
HOME HEALTHCARE APPLICATION
NOTICE: PART OR ALL OF THE POLICY FOR WHICH THIS APPLICATION IS MADE IS WRITTEN ON A
CLAIMS MADE AND REPORTED BASIS, WHICH MEANS THAT THE POLICY APPLIES ONLY TO ANY
CLAIM FIRST MADE AGAINST THE INSUREDS AND REPORTED IN WRITING TO THE INSURER
DURING THE POLICY PERIOD OR THE OPTIONAL EXTENSION PERIOD, IF APPLICABLE. AMOUNTS
INCURRED AS CLAIMS EXPENSES SHALL REDUCE AND MAY EXHAUST THE LIMIT OF LIABILITY
AND ARE SUBJECT TO THE DEDUCTIBLE. PLEASE READ THIS APPLICATION CAREFULLY.
BACKGROUND INFORMATION – PLEASE READ:
1. Please type or print clearly.
2. Answer ALL questions completely leaving no blanks. If any questions, or part thereof, do not apply, print
N/A in the space.
3. If additional space is needed to answer any questions fully, please attach a separate page.
4. This application must be completed, dated and signed by a Principal of the Applicant.
Requested Attachments:
1. Loss History for the last FIVE years.
2. Most recent local and/or State accreditation agency reports (if applicable).
3. Copy of expiring declarations page if retroactive coverage is being requested
I. APPLICANT INFORMATION:
a) Name of Applicant/Entity(s)________________________________________________________
______________________________________________________________________________
b) Date of Incorporation/Start of Operations: ____________________________________________
c) Physical Address (City, State, Zip Code) _____________________________________________
_____________________________________________________________________________
d) Telephone______________________ Website__________________
e) List names, location, and descriptions of all legal entities, including subsidiaries for which Applicant
is a part (continue on a separate sheet if necessary)
Loc. #
Business Name
and Address
Description
Date
Acquired
Ownership
%
Retroactive
Date
f) Have you sold, discontinued, changed, or acquired any operations in the past 5 years, or do you
plan to in the upcoming year? (Please including name of entity and date acquired) ... Yes No
__________________________________________________________________________
__________________________________________________________________________
■
Submit Application
Page 2 of 6
g) List all licenses and/or any/all accreditation from governmental agencies/clients held by your
facility including type and expiration dates.
II. COVERAGE HISTORY:
a) Please provide details of professional liability coverage purchased in the last five (5)
years to date:
Policy
Period
Primary/Xs
Limit
SIR/Deductible
Carrier
Annual
Premium
Occurrence
or Claims
Made?
Retroactive
Date
b) Please provide details of general liability coverage purchased in the last five (5)
years to date:
Policy
Period
Primary/Xs
Limit
SIR/Deductible
Carrier
Annual
Premium
Occurrence
or Claims
Made?
Retroactive
Date
c) Do you currently carry employee benefits liability coverage? ............................. Yes No
If yes, what is the employee count, limit, deductible, and retroactive date?
___________________________________________________________________________
d) Has the applicant ever been declined or refused coverage, or had its coverage cancelled or
non-renewed? ..................................................................................................... Yes No
If yes, please explain.
____________________________________________________________________________________________
III. PROFESSIONAL SERVICE/PRODUCT AND MEDICAL STAFF PROFILE:
a) Please provide a full description of services rendered.
1. Locations where services are provided (total must equal 100%):
_____% Private Home _____% Nursing Home _____% Assisted Living Facility
_____% Hospice _____%Hospital _____% Physician’s Office
_____% Physical Rehab Facility _____% Psychiatric Facility _____%Substance Abuse Facility
_____% Correctional Facility _____% Other Facility (please specify)_____________________
2. Type of services (identify percentage, if any):
_____% Skilled Nursing _____% Assistive Nursing _____% Labor & Delivery/Obstetrics
_____% Correctional _____%Pain Management _____% Sitter/Companion Care
_____% ICU (Intensive Care) _____% Surgical/OR _____% Tracheostomy/Ventilator
_____% Emergency Department _____% Other Facility (please specify)_____________________
3. Age of Clients: _____% younger than 18; _____% 18 to 60 yrs old; _____% older than 60
4. Projected annual revenue:
Page 3 of 6
Projected, next
Fiscal/Annual Period
Past 12 Months; Most
recent, full-annual
First Year Prior
Financial Year:
Gross Revenues:
5. Annual Employee Staffing:
6. Do you run criminal background checks on all staff? ..................................... Yes No
7. Are sex offender registry checks performed on all staff? ............................... Yes No
8. Annual Independent Contractor Staffing:
9. Do independent contractors carry their own insurance? ............................... Yes No
If yes, what limits?
_______________________________________________________________________________________
10. Are you requesting coverage for independent contractors? ........................... Yes No
Type of Employee
Full-
Time
Part-
Time
Billable Hours
Last 12 Months
Billable Hours
Next 12 Months
Annual Payroll
Registered Nurses
Licensed Practical Nurses
Licensed Vocational Nurses
Nurse Practitioners
Physician Assistants
Certified Nurse Assistants
Home Health Aids
Sitters/Companions (non-
medical)
Homemakers (non-medical)
Social Workers/Counselors
Respiratory Therapists
Speech/Occupational/Physical
Therapists
Other (specify)
Type of Independent
Contractor
Full-
Time
Part-
Time
Billable Hours
Last 12 Months
Billable Hours
Next 12 Months
Annual Payroll
Registered Nurses
Licensed Practical Nurses
Licensed Vocational Nurses
Nurse Practitioners
Physician Assistants
Certified Nurse Assistants
Home Health Aids
Sitters/Companions (non-
medical)
Homemaker (non-medical)
Social Worker/Counselor
Respiratory Therapist
Speech/Occupational/Physical
Therapists
Other (specify)
Page 4 of 6
11. Do you require all Nursing Homes/Assisted Living/Long Term Care Facilities to carry
Professional and General Liability Coverage?.................................................................... Yes No
If yes, what limits?
____________________________________________________________________________________________
12. Are all health professionals credentialed prior to hiring?..................................... Yes No
13. Prior to hiring any employee, does the applicant verify:
Education background and training?............................................................. Yes No
Employment references with at least two previous employers?................... Yes No
Criminal record, on a Local, State and National scale? (Please indicate which apply)
_______________________________________________________________________
Driving record?............................................................................................. Yes No
Credit record?............................................................................................... Yes No
Drug tests?.................................................................................................... Yes No
Sex Offender Registry?................................................................................. Yes No
14. Does the applicant keep all information on file and verify its completion prior to employment
commencement?.................................................................................................. Yes No
15. Does the applicant confirm that the Insured annually checks MVRs and requires all drivers to
carry a minimum of $100,000/$300,000 in personal auto insurance?................. Yes No
IV: PRIVACY
a) Does the Applicant have a written corporate-wide privacy policy? ............................ Yes No
If yes, please attach a copy.
b) Does the Applicant collect, store, maintain or transmit personally identifiable consumer
information? ............................................................................................................... Yes No
If yes, does such information include:
Information subject to regulation under HIPAA.............................................. Yes No
Information subject to regulation under GLB.................................................. Yes No
Credit card information................................................................................... Yes No
Other personally identifiable consumer information (please describe): ......... Yes No
c) Does any Applicant, director, officer, employee or other proposed Insured have knowledge or
information of any fact, circumstance, situation, event or transaction which may give rise to a
Claim against any Insured for invasion of or interference with any right of privacy, wrongful
disclosure of personal information, or violation of any privacy related statute or regulation?
If “yes”, please explain: .............................................................................................. Yes No
______________________________________________________________________________
d) During the past three years, has anyone made any Claim against the Applicant for invasion of or
interference with any right of privacy, wrongful disclosure of personal information, or violation of any
privacy related statute or regulation? .......................................................................... Yes No
_______________________________________________________________________________
V. INSURED HISTORY - CLAIMS, LOSSES, AND INCIDENTS:
a) Has any claim or suit for an error, omission or malpractice ever been made against you or your
organization or any employees/staff working on your behalf?............................... Yes No
If Yes, how many? ____ Complete a copy of our Supplemental Claim form for each
b) Are you or any proposed insured for this insurance aware of any claim or suit, or any act, error,
omission, fact, circumstance, or records request from any attorney which may result in a
malpractice, general liability, or products liability claim or suit?............................. Yes No
If Yes, has each of these been reported to the current or any prior insurer?......... Yes No
How many? Complete a copy of our Supplemental Claim form for each
c) Has the applicant or any staff:
i. ever been the subject of disciplinary/investigative proceedings or reprimand by a
governmental/administrative agency, hospital or professional association? Yes No
ii. ever been convicted for an act committed in violation of any law or ordinance other than
traffic offenses? ............................................................................................ Yes No
iii. ever been treated for alcoholism or drug addiction? .................................... Yes No
Page 5 of 6
iv. ever had any state professional license or license to prescribe or dispense narcotics
refused, suspended, revoked, renewal refuses or accepted only on special terms or ever
voluntarily surrendered same? ..................................................................... Yes No
(If yes, please provide an explanation on any/all incidents)
______________________________________________________________________________________
THE UNDERSIGNED IS AUTHORIZED BY THE APPLICANT AND DECLARES THAT THE STATEMENTS SET
FORTH HEREIN AND ALL WRITTEN STATEMENTS AND MATERIALS FURINSHED TO THE INSURER IN
CONJUNCTION WITH THIS APPLICATION ARE TRUE. SIGNING OF THIS APPLICATION DOES NOT BIND
THE APPLICANT OR THE INSURER TO COMPLETE THE INSURANCE, BUT IT IS AGREED THAT THE
STATEMENTS CONTAINED IN THIS APPLICATION, ANY SUPPLEMENTAL ATTACHMENTS, AND THE
MATERIALS SUBMITTED HEREWITH ARE THE BASIS OF THE CONTRACT SHOULD A POLICY BE ISSUED
AND HAVE BEEN RELIED UPON BY THE INSURER IN ISSUING ANY POLICY.
THIS APPLICATION AND MATERIALS SUBMITTED WITH IT SHALL BE RETAINED ON FILE WITH THE
INSURER AND SHALL BE DEEMED ATTACHED TO AND BECOME PART OF THE POLICY IF ISSUED. THE
INSURER IS AUTHORIZED TO MAKE ANY INVESTIGATION AND INQUIRY IN CONNECTION WITH THIS
APPLICATION AS IT DEEMS NECESSARY.
THE APPLICANT AGREES THAT IF THE INFORMATION SUPPLIED ON THIS APPLICATION CHANGES
BETWEEN THE DATE OF THIS APPLICATION AND THE EFFECTIVE DATE OF THE INSURANCE, THE
APPLICANT WILL, IN ORDER FOR THE INFORMATION TO BE ACCURATE ON THE EFFECTIVE DATE OF
THE INSURANCE, IMMEDIATELY NOTIFY THE INSURER OF SUCH CHANGES, AND THE INSURER MAY
WITHDRAW OR MODIFY ANY OUTSTANDING QUOTATIONS OR AUTHORIZATIONS OR AGREEMENTS TO
BIND THE INSURANCE
I HAVE READ THE FOREGOING APPLICATION OF INSURANCE AND REPRESENT THAT THE RESPONSES
PROVIDED ON BEHALF OF THE APPLICANT ARE TRUE AND CORRECT.
WARNING
ANY PERSON WHO, WITH INTENT TO DEFRAUD OR KNOWING THAT (S)HE IS FACILITATING A
FRAUD AGAINST THE INSURER, SUBMITS AN APPLICATION OR FILES A CLAIM CONTAINING A
FALSE OR DECEPTIVE STATEMENT MAY BE GUILTY OF INSURANCE FRAUD.
COLORADO: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurer to
defraud or attempt to defraud the insurer. Penalties may include imprisonment, fines, denial of insurance, and civil
damages. Any insurer or agent of an insurer 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.
DISTRICT OF COLUMBIA: 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 and an insurer may deny
insurance benefits if false information materially related to a claim made by the applicant.
FLORIDA: 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 the third degree.
LOUISIANA AND MARYLAND: Any person who knowingly and willfully presents a false or fraudulent claim for
payment of a loss or benefit or who knowingly and willfully presents false information in an application for insurance is
guilty of a crime and may be subject to fines and confinement in prison.
MAINE, TENNESSEE, VIRGINIA AND WASHINGTON: It is a crime to knowingly provide false, incomplete or
misleading information to an insurer to defraud the insurer. Penalties may include imprisonment, fines or denial of
insurance benefits.
MINNESOTA: A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a
crime.
OKLAHOMA: 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 information is guilty of a felony.
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.
NEW YORK AND KENTUCKY: Any person who knowingly and with intent to defraud an insurer or other person files
an application for insurance or statement of claims 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. New York applicants are subject to a civil penalty not to exceed $5,000 and the stated value of the claim for each
such violation. Pennsylvania applicants are subject to criminal and civil penalties.
Page 6 of 6
Signed: .
Date:____________________________________________________
Print Name: ______________________________________________
Title: ____________________________________________________
(Owner, Partner, Authorized Officer)
If this Application is completed in Florida, please provide the Insurance Agent’s name and license number. If this
Application is completed in Iowa or New Hampshire, please provide the Insurance Agent’s name and signature only.
Agent’s Printed Name:
Florida Agent’s License Number:
Agent’s Signature:
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HOME HEALTHCARE APPLICATION (RT Specialty)

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Completed 13 December 2020

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