Fillable HOME MEDICAL EQUIPMENT SUPPLEMENTAL APPLICATION (Philadelphia Insurance Companies)

Fill Online, Printable, Fillable, Blank HOME MEDICAL EQUIPMENT SUPPLEMENTAL APPLICATION (Philadelphia Insurance Companies) Form

Use Fill to complete blank online PHILADELPHIA INSURANCE COMPANIES pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

HOME MEDICAL EQUIPMENT SUPPLEMENTAL APPLICATION (Philadelphia Insurance Companies)

On average this form takes 148 minutes to complete

The HOME MEDICAL EQUIPMENT SUPPLEMENTAL APPLICATION (Philadelphia Insurance Companies) form is 9 pages long and contains:

  • 0 signatures
  • 50 check-boxes
  • 567 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your Philadelphia Insurance Companies forms online.

BROWSE PHILADELPHIA INSURANCE COMPANIES FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
HOME MEDICAL EQUIPMENT SUPPLEMENTAL APPLICATION
Pages 1 –
2 and the Fraud Statement must be completed on all submissions.
1.
If you would like a quote for Abuse & Molestation, complete Page 3.
2.
If you would like a quote for Professional Liability, complete Page 3 - 6.
Applicant Name:
DBA:
(If more than one entity/subsidiary, please attach description and % owned for each)
For Profit
Partnership
Other (specify):
Is the Applicant’s organization more than 25% owned by a private equity fund structure?
Yes
No
If yes, provide name of private equity firm:
Address:
City:
State:
Zip:
Telephone:
Fax:
Date business established:
# of years under present management:
Federal Employer Tax I.D. Number:
Website address (if available):
Name and phone number of person to contact for inspection:
Risk Management Contact:
Risk Management’s Phone:
Risk Management Email:
SUBMISSION REQUIREMENTS
•
PHLY Home Medical Equipment Dealer Supplemental Application
•
ACORD Applications (Applicant Information, including Crime and Umbrella)
•
Currently valued insurance company loss runs for the current policy period and four prior years
SECTION I - APPLICANT INFORMATION
1.
Limits of liability desired:
$500,000/$1,000,0000
$1,000,000/$1,000,000
$1,000,000/$2,000,000
$1,000,000/$3,000,000
Other:
$
Occurrence / $
Aggregate
2.
Has the Applicant ever carried insurance that was on a Claims Made basis?
Yes
No
If yes, what is the Retro Date?
3.
Total annual Gross Revenues:
$
Total receipts from Retail:
$
Total receipts from Rentals:
$
Total receipts from Wholesale:
$
Total receipts from Professional Services:
$
4.
Is the Applicant a member of any State Association?
Yes
No
If yes, please provide the name of the State Association:
5.
Is the Applicant a member of any other industry association(s)?
Yes
No
Please specify:
6.
Does the applicant manufacture or directly import any products?
Yes
No
If yes, please explain:
Home Medical Equipment
Supplemental Application
Page 1 of 9
© 2019 Philadelphia Consolidated Holding Corp
01/2019
Print Application
Clear Application
Products Offered: (percentages must equal 100%)
Product
Product
Antibiotics Therapy
%
Oxygen regulators and valves
%
Apnea monitors
%
Parenteral Therapy
%
Apnea monitors - infant
%
Pharmacy Sales
%
Auto conversions / modifications
%
Photo therapy equipment - infants
%
Beds, commodes
%
Scooters
%
Blood Cleansing or recirculation
Safety bar / Grab bar installation
%
equipment
%
Safety bar / Grab bar sales
%
Chemotherapy
%
Sleep apnea Studies
%
CPAP / BIPAP
%
Stair lift - installation
%
CPM
%
Stair lift – sales
%
Diabetic Shoes
%
Tens Units
%
Enteral Therapy
%
Ventilators
%
Infant beds or cribs
%
Do you instruct on the use of ventilators? Yes No
Liquid Oxygen
%
%
Walkers, crutches, canes
%
Medical gas piping
Wheel chair - motorized
%
Nebulizers
%
Wheel chair – manual
%
Orthotics & prosthetic sales or fitting
%
Other:
%
Oxygen Concentrators
%
Other:
%
Oxygen Cylinders
%
ABOVE MUST TOTAL 100%:
%
7.
Is the Applicant named as an Additional Insured – Vendor on the manufacturer’s or supplier’s
policy for products?
Yes
No
8.
Does the Applicant obtain certificates of insurance from their product suppliers?
Yes
No
9.
Has the Applicant ever distributed or directly imported products from a foreign manufacture?
Yes
No
10.
Does the Applicant modify any product in any way from its intended use?
Yes
No
If yes, please explain:
11.
Does the Applicant repackage or re-label any items obtained from suppliers?
Yes
No
12.
Do the manufacture’s labels remain on the equipment?
Yes
No
13.
Are serial numbers of the finished product shown on invoices and complete records of inventory
kept?
Yes
No
14.
Does the Applicant contract or subcontract labor for any installation, service or repair of any
equipment?
Yes
No
If yes, please explain.
15.
If oxygen is offered, does the applicant offer a 24 hour service program?
Yes
No
16.
Does the Applicant service any products not sold or rented by you?
Yes
No
If yes, please explain:
17.
Does the Applicant repair or perform maintenance on any medical supplies or equipment?
Yes
No
If yes, please explain:
18.
Does the Applicant provide reconditioning service for mobility equipment?
Yes
No
If yes, please explain:
19.
Are all areas of buildings with wet pipe sprinkler systems (hidden or unhidden) maintained at a
minimum temperature of 40° F, and / or provided with proper insulation or heat tracing to prevent
pipe freeze-ups?
Yes
No
Home Medical Equipment
Supplemental Application
Page 2 of 9
© 2019 Philadelphia Consolidated Holding Corp
01/2019
Print Application
Clear Application
SECTION II - ABUSE AND MOLESTATION
N/A
1.
Does the Applicant current insurance program include Abuse and Molestation coverage?
Yes
No
If yes, what are the limits? $
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 you have an incident of abuse?
Yes
No
4.
Are there written complaint procedures and are they displayed prominently?
Yes
No
If no please explain:
5.
Are there written procedures that monitors staff in day-to-day relationships with clients, both on and
off premises?
Yes
No
6.
Is there formal staff training on sexual abuse, including how to recognize the signs?
Yes
No
7.
Is there more than one person responsible for the welfare of any single patient?
Yes
No
8.
Have any incidents resulted in an allegation of sexual abuse?
Yes
No
9.
Was the case settled?
Yes
No
10.
Was the case taken to trial?
Yes
No
11.
Amount paid for damages to the victim: $
12.
Does the applicant provide equipment, services or therapy to minors?
Yes
No
SECTION III - PROFESSIONAL LIABILITY
N/A
Supplemental Services (Supplying health care providers to other facilities for a fee): IF “NO” check here:
Type
Type
Private Homes
%
Hospitals
%
Doctor’s Offices
%
Nursing Homes
%
Assisted Living Facilities
%
Other:
%
Professional Liability Employees / Independent Contractors – Annual Staffing:
1.
Annual Staffing – Employees, Independent Contractors and Volunteers
Total number of:
Full time employees:
Part Time Employees:
Volunteers:
Staffing
# of Employees # of Contracted
Total Annual Volunteer
Hours Worked
FT
PT
FT
PT
Psychologist
Medical Director (Admin Only)
Nurse Practitioner
Physician Assistant
Pharmacist
Paramedic EMT
Psychiatrist
Physician-Hospice
Pediatrician
Physician-No Surgery
Dentist
Optometrists/Ophthalmologist
Licensed Social Worker
Sociologist
Registered Nurse (RN)
Licensed Practical Nurse (LPN)
Physical Therapist
Optician
Orthotics & Prosthetics (O&P)
Certified Practitioner
Counselor (Guidance,
Vocational)
Social Worker
Occupational Therapist
Speech Therapist
Home Medical Equipment
Supplemental Application
Page 3 of 9
© 2019 Philadelphia Consolidated Holding Corp
01/2019
Print Application
Clear Application
Clergy / Rabbi / Pastor
O&P Certified Technician
Teacher
Nutritionist / Dietician
Residential Manager
Home Health Aide
Day Care Worker
O&P Certified Fitter
O&P Certified Assistant
Adoptions
Foster Care
*Other (describe):
*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.
2.
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.
3.
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.
4.
Describe any additional contracted Home Health Care operations (if different from above types):
5.
Describe any changes in operations planned within the next year:
6.
Has the Applicant ever been under investigation or convicted by any state or local authorities, the
FBI or Department of Justice?
Yes
No
If yes, please explain:
7.
Have any claims / suits been made within the last five years against the Applicant?
Yes
No
If yes, please attach copy of insurance company loss reports for each claim or suit. (Specify date,
description, amount paid and amount outstanding for each claim).
8.
Is the Applicant aware of any circumstances which may result in any claim or suit made (including
request for medical records)?
Yes
No
If yes, please explain:
9.
Has any company declined, canceled or refused to renew any of the Applicant’s Professional
Liability Insurance?
Yes
No
If yes, please explain:
10.
Previous Professional Liability Insurance (past five years):
Company
Limits of
Liability
Effective Dates
Annual
Premium
Claims Made
Form or
Occurrence
Form
Retroactive Date
(Claims Made
only)
$
$
$
$
$
11.
Limits of Liability Desired:
$500,000/$1,000,000
$1,000,000/$1,000,000
$1,000,000/$2,000,000
$1,000,000/$3,000,000
Other:
$
Occurrence / $
Aggregate
Home Medical Equipment
Supplemental Application
Page 4 of 9
© 2019 Philadelphia Consolidated Holding Corp
01/2019
Print Application
Clear Application
SECTION IV - PROFESSIONAL LIABILITY HIRING / SCREENING
N/A
1.
Are all employees and contractors screened to rule out drug, alcohol and sexual abuse?
Yes
No
2.
Check all methods used in hiring all employees or independent contractors:
•
Drug Testing
Yes
No
•
Criminal Background Checks – Federal
Yes
No
•
Criminal Background Checks – State
Yes
No
•
Reference Checks
Yes
No
• Personal Interview
Yes No
• Sexual Abuse Registry
Yes
No
•
Validate Work History
Yes
No
•
Validate Education
Yes
No
•
Verify Current Certification / Professional License
Yes
No
•
Validate Driver’s License
Yes
No
• Validate Personal Auto Insurance and Limits (if operating owned vehicle during company hours)
Yes
No
3.
How are references checked:
Written
Verbal
Both
If verbal only, please explain:
4.
Are all of the above methods done prior to hiring?
Yes
No
If “no”, please explain:
5.
Are job descriptions provided for all professional and nonprofessional employees?
Yes
No
6.
Does the Applicant verify certificate and / or professional licensure status of employees and
independent contractors?
Yes
No
7.
What is the average staff turnover rate:
8.
Does the Applicant question prospective employees about any previous involvement as defendants
in professional malpractice litigation?
Yes
No
If no, please explain:
9.
Does the Applicant verify if potential employees and or independent contractors have ever had their
license revoked or suspended, or disciplinary action taken against them?
Yes
No
SECTION V - PROFESSIONAL LIABILITY RISK MANAGEMENT
N/A
1.
Does the Applicant utilize a formal written Quality Assurance Risk Management Program?
Yes
No
If no, please explain:
2.
Does the Applicant verify certificate and / or professional licensure status of employees and
independent contractors?
Yes
No
3.
Are employees required to carry their own individual professional liability coverage?
Yes
No
Limits of Liability: $
4.
Are independent contractor’s required to carry their own individual professional liability coverage?
Yes
No
Limits of Liability: $
5.
Are certificates of insurance maintained on file for all employees and independent contractors and
updated annually?
Yes
No
6.
Does the Applicant have formal HIPAA compliance procedures in place?
Yes
No
7.
Has the Applicant developed written protocols that govern the admission and medical treatment of
patients for the following policies and procedures:
a.
Complete treatment plan prescribed by the physician, including follow up plans?
Yes
No
b.
Assessments of clients prior to and after accepting the clients?
Yes
No
c.
Client’s care and home visits documented?
Yes
No
d.
Documentation of all homecare training?
Yes
No
e.
All changes in the condition of the client or incidents involving the client documented in the
records and reported to the family and physician? Yes No
8.
Is the overall responsibility for Risk Management assigned to one individual in your organization?
Yes
No
Home Medical Equipment
Supplemental Application
Page 5 of 9
© 2019 Philadelphia Consolidated Holding Corp
01/2019
Print Application
Clear Application
9.
Does the Applicant have a formal incident report procedure in place?
Yes
No
10.
Is there a peer or committee who review the incident reports to improve upon any allegations
previously outlined in the surveys or reports?
Yes
No
11.
Does the Applicant have formal documented training in place for the following:
a.
Crisis Management
Yes
No
b.
Disposal of Medical waste
Yes
No
c.
First Aid
Yes
No
d.
AED Training
Yes
No
e.
Infusion Therapy
Yes
No
f.
Safe lifting, transferring, and client handling
Yes
No
g.
Blood borne Pathogen
Yes
No
h.
Safe use of equipment
Yes
No
i.
Other (please list):
12.
Are companion care providers certified through the National Association for Home Care and
Hospice (NAHC)?
Yes
No
13.
Do all contracts with pharmacies, durable medical equipment suppliers, hospitals, nursing home and
assisted living homes include a hold harmless agreement?
Yes
No
14.
Is the staff informed of AIDS/HIV Patients?
Yes
No
15.
Do patient records include the following:
a.
A complete treatment plan prescribed by a physician, including follow-up plans?
Yes
No
b. An “informed consent” document obtained and placed in the patient’s medical record?
(informed consent laws vary by state)
Yes
No
c.
Patient care home visits meticulously documented?
Yes
No
d.
Complete medical records maintained on all patients?
Yes
No
e.
Patient records kept on file (hardcopy of electronic) for a minimum of 6 years?
Yes
No
f.
All changes in condition and incidents documented to the physician and family?
Yes
No
g.
Is documentation of all homecare training provided?
Yes
No
h.
Medications & dosage, including documentation of administering medications?
Yes
No
i.
A copy of literature given to clients explaining services and fees?
Yes
No
j.
Termination of services and discharge criteria?
Yes
No
16.
Does the Applicant conduct patient / client surveys?
Yes
No
17.
Are the results of patient / client surveys used to improve day to day operations?
Yes
No
18. Are medications ordered by a licensed physician and administered by or under the close
supervision of a qualified medical professional?
Yes
No
19.
Are medications kept in a locked area to prevent tampering?
Yes
No
20.
Describe the organization’s policy for disposal of controlled substances?
SECTION VI – CLAIMS MADE
N/A
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 proceed 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 the Applicant?
Yes
No
If yes, please provide details:
2.
With respect to the coverages applied for, upon inquiry of any of 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?
Yes
No
If yes, please provide details:
If yes, please list name and title:
If no, please describe how these functions are monitored:
Home Medical Equipment
Supplemental Application
Page 6 of 9
© 2019 Philadelphia Consolidated Holding Corp
01/2019
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 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 Medical Equipment
Supplemental Application
Page 7 of 9
© 2019 Philadelphia Consolidated Holding Corp
01/2019
Print Application
Clear 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
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
SECT
ION 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)
PI-CYBE-APP (11/16)
Page 2 of 2
Clear Application
Print Application
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

HOME MEDICAL EQUIPMENT SUPPLEMENTAL APPLICATION (Philadelphia Insurance Companies)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 29 July 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document