Fillable Halfway House General Liability Application (RT Specialty)

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Halfway House General Liability Application (RT Specialty)

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The Halfway House General Liability Application (RT Specialty) form is 7 pages long and contains:

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  • 35 check-boxes
  • 315 other fields

Country of origin: US
File type: PDF

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Scottsdale Insurance Company
Home Office: One Nationwide Plaza
Columbus, Ohio 43215
Adm. Office: 8877 North Gainey Center Drive
Scottsdale, Arizona 85258
Scottsdale Surplus Lines Insurance Company
Adm. Office: 8877 North Gainey Center Drive
Scottsdale, Arizona 85258
Scottsdale Indemnity Company
Home Office: One Nationwide Plaza
Columbus, Ohio 43215
Adm. Office: 8877 North Gainey Center Drive
Scottsdale, Arizona 85258
1-800-423-7675 • Fax (480) 483-6752
www.scottsdaleins.com
Halfway House General Liability Application
Applicant’s Name:
Mailing Address:
Location Address:
Web site Address:
Agency Name:
Agent:
Address:
E-Mail:
Phone:
PROPOSED EFFECTIVE DATE: From To 12:01 A.M., Standard Time at the address of the Applicant
ANSWER ALL QUESTIONS—IF THEY DO NOT APPLY, INDICATE “NOT APPLICABLE”
Applicant is: Individual Corporation Partnership Joint Venture
Limited Liability Company Other (Specify):
Limits Of Liability and Deductible Requested:
General Aggregate (other than Products/Completed Operations)
$
Products & Completed Operations Aggregate $
Personal & Advertising Injury (any one person or organization) $
Each Occurrence $
Damage To Premises Rented To You (any one premise) $
Medical Expense (any one person) $
Errors and Omissions Coverage Each Claim
(Limits must be equal to General Liability limits) Aggregate
$
$
Sexual and/or Physical Abuse Coverage $ 25,000/$ 50,000 (included)
$ 50,000/$100,000
$100,000/$300,000
Other Coverages, Restrictions, and/or Endorsements: $
Deductible $
GLS-APP-41s (7-12) Page 1 of 7
Submit Here
1. Applicant operates as: Profit Nonprofit Number of years in operation:
2. How long under present management? (If fewer than five years, attach principals’ resumes. If
principals in the firm do not have a health care background, then also include the resume of the individual responsible
for hiring, screening and monitoring the work activities of employees.)
3. Is facility owned by physician(s)? ........................................................................................................... Yes No
If yes, is physician(s) involved in day-to-day operations? ........................................................................... Yes No
4. Type of operation:
Birth control, pregnancy or abortion counseling/clinic Mission or settlement house
Blood testing or communicable disease clinic Non-medical drug and alcohol rehabilitation center
Crises center (rape, domestic violence, etc.) Outpatient aftercare and support program (AA,
Halfway house Al-Anon, etc.)
Healthcare clinic Outpatient counseling or guidance center
Homeless shelter Prisoners work-release or rehabilitation program
Hospice facility Psychiatric institution
Medical urgent care facility Youth hostel
Describe type of operation and services provided (attach brochure and/or advertising material if available):
5. Does applicant provide any off-premises health care services? ......................................................... Yes No
If yes, advise:
6. Total number of employees:
7. As part of hiring/screening of new employees, does applicant:
a. Obtain copies of their professional licenses/certifications? .................................................................. Yes No
b. Contact applicants’ references before they are hired? ......................................................................... Yes No
c. Require that they carry their own professional liability policy? ............................................................. Yes No
8. Operations conducted in the following states:
State: Licensed with state? ............ Yes No License No.:
State: Licensed with state? ............ Yes No License No.:
State: Licensed with state? ............ Yes No License No.:
9. Has license ever been revoked? .............................................................................................................. Yes No
If yes, explain:
10. Name all subsidiary companies/locations and others coming under applicant’s control: (if none, please state)
11. Has applicant sold, acquired or discontinued any operations in the last five years? ....................... Yes No
If yes, explain:
12. Is at least one of the principals or an Administrator/Director involved in the operation on a full-
time basis? .................................................................................................................................................
Yes No
GLS-APP-41s (7-12) Page 2 of 7
13. Physical features of risk:
a. Year built:
b. Construction of building:
c. Number of floors: On which floor(s) is applicant located?
Square foot area occupied by applicant:
d. Equipped with sprinkler system? .......................................................................................................... Yes No
Equipped with fire alarm? ...................................................................................................................... Yes No
If yes: Central station Local alarm
Equipped with smoke detectors? .......................................................................................................... Yes No
If yes, how many on each floor?
e. Number of fire extinguishers on premises: Number of fire escapes:
f. Is smoking allowed on premises? ......................................................................................................... Yes No
If yes, where is it permitted?
g. Is there a swimming pool or hot tub/spa on premises? ........................................................................ Yes No
If yes:
• Number of pools?
• Are the pools fully fenced with self-latching gates? ........................................................................ Yes No
• Are the rules posted? ..................................................................................................................... Yes No
• Is there life-safety equipment at poolside? ..................................................................................... Yes No
• Is there a diving board, platform, or slide? ..................................................................................... Yes No
If yes, height of each:
• Are all swimming pools, wading pools, hot tubs and spas in compliance with the federal
Virginia Graeme Baker Pool and Spa Safety Act? .........................................................................
Yes No
h. Was building originally built for this type of occupancy? ....................................................................... Yes No
14. Evacuation procedures:
a. Does applicant have a written Emergency Evacuation Plan? .............................................................. Yes No
b. Does evacuation plan include advance agreement for transportation and temporary shelter? ........... Yes No
c. Are evacuation procedures posted in all parts of the facility? ............................................................... Yes No
If yes, are posted evacuation procedures bilingual? ............................................................................. Yes No
d. How often are drills conducted?
15. State patients’/residents’ ages: Youngest Oldest Average age
16. Physicians on premises, if any, are:
Private practitioners (personal physicians of the residents)
Employees of applicant
Contracted physicians through written contract with applicant
If contracted physician, are certificates/evidence of professional liability insurance required and
kept on file? ...........................................................................................................................................
Yes No
17. Do services provided include?
Infusion therapy? ......................................................................................................................................... Yes No
Dialysis? ...................................................................................................................................................... Yes No
Physical therapy? ........................................................................................................................................ Yes No
Does treatment process involve the administration of methadone or other drugs? .................................... Yes No
18. Are employees authorized to use their personal vehicles to transport residents or patients? ........ Yes No
GLS-APP-41s (7-12) Page 3 of 7
19. Are residents/patients placed in applicant’s facility by court order? .................................................. Yes No
20. Any involvement in medical detoxification? .......................................................................................... Yes No
21. Does facility accept prisoners? ............................................................................................................... Yes No
22. Does facility accept teens with a past history of violence or attempted suicide? ............................. Yes No
23. Does facility provide pregnancy and/or abortion counseling services? ............................................. Yes No
24. Does facility, if an inpatient facility, accept children under the age of eighteen (18)? ...................... Yes No
If yes, does applicant also require the child’s guardian to be in residence at the same facility? ................ Yes No
25. Is facility a foster home or foster care facility? ...................................................................................... Yes No
26. Does facility provide inpatient services or permanent housing for either of the following:
a. Developmentally Disabled—Adults or children able to care for themselves despite their disability
or mental retardation. Examples of this category include Downs Syndrome, autism and brain
injuries. This category does not include individuals whose primary diagnosis is an emotional or
mental illness. .......................................................................................................................................
Yes No
b. Mentally Disabled—Adults or children able to care for themselves (with substantial numbers able
to hold jobs). Behavior is controlled through medication and monitored by their personal physician.
This category would include individuals whose primary diagnosis is an emotional or mental illness
including but not limited to schizophrenia, psychopathic and sociopathic diagnosis............................
Yes No
27. Does applicant provide bed and board facilities? ................................................................................. Yes No
If yes, number of beds:
Length of stay: From (shortest) To (longest) Average
28. Does applicant provide outpatient services? ......................................................................................... Yes No
If yes, number of annual outpatient visits:
29. Explain arrangement for medical emergencies (i.e., M.D. on call, transfer arrangements with hospital, etc.):
30. Does applicant have Workers’ Compensation coverage in force? ...................................................... Yes No
31. Does applicant have any contractual agreements wherein applicant assumes the liability of
others? ........................................................................................................................................................
Yes No
If yes, attach a list of each entity that has requested to be named as an additional insured and the type of service(s)
applicant provides.
32. Any other premises or operations exposures not stated in this application? ................................... Yes No
If yes, attach a complete description and underwriting/rating information.
33. During the past five years, have any claims been made or suits brought against the applicant
because of alleged malpractice, error, mistake or premises accident arising in any manner out
of applicant’s operation? ..........................................................................................................................
Yes No
If yes, advise date and details:
34. Additional Insured Information:
Name Address Interest
GLS-APP-41s (7-12) Page 4 of 7
35. During the past three years, has any company canceled, declined, or refused similar insurance
to the applicant? (Not applicable in Missouri) ...........................................................................................
Yes No
If yes, explain:
36. Does risk engage in the generation of power, other than emergency back-up power, for their
own use or sale to power companies?....................................................................................................
Yes No
If yes, describe:
37. Does applicant have other business ventures for which coverage is not requested? ...................... Yes No
If yes, explain and advise where insured:
38. Schedule of Hazards:
Loc.
No.
Classification Description
Class.
Code
Exposure
Premium Basis
(s) Gross Sales
(p) Payroll
(a) Area
(c) Total Cost
(t) Other
39. Prior Carrier Information:
Year:
Year:
Year:
Year:
Year:
Carrier
Policy Number
Coverage
Occurrence or
Claims Made
Total Premium $
$
$
$
$
40. Loss History:
Indicate all claims or losses (regardless of fault and whether or not insured) or occurrences that may give
rise to claims for the prior five years. Check if no losses last five years.
Date of
Loss
Description of Loss Amount Paid
Amount
Reserved
Claim Status
(Open or Closed)
$
$
$
$
$
$
$
$
$
$
This application does not bind the applicant nor the Company to complete the insurance, but it is agreed that the infor-
mation contained herein shall be the basis of the contract should a policy be issued.
GLS-APP-41s (7-12) Page 5 of 7
FRAUD WARNING: Any person who knowingly and with intent to defraud any insurance company or other person files an
application for insurance or statement of claim containing any materially false information or conceals for the purpose of
misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and
subjects such person to criminal and civil penalties. Not applicable in Nebraska, Oregon and Vermont.
NOTICE TO COLORADO APPLICANTS: It is unlawful to knowingly provide false, incomplete, or misleading facts or in-
formation to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may
include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance
company who knowingly provides false, incomplete, or misleading facts or information to a policy holder or claimant for
the purpose of defrauding or attempting to defraud the policy holder or claimant with regard to a settlement or award pay-
able from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory
Agencies.
WARNING TO DISTRICT OF COLUMBIA APPLICANTS: It is a crime to provide false or misleading information to
an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In
addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the
applicant.
NOTICE TO FLORIDA APPLICANTS: Any person who knowingly and with intent to injure, defraud, or deceive any in-
surer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a
felony in the third degree.
NOTICE TO LOUISIANA APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a
loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be sub-
ject to fines and confinement in prison.
NOTICE TO MAINE APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an
insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of
insurance benefits.
NOTICE TO MARYLAND APPLICANTS: Any person who knowingly 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.
NOTICE TO MINNESOTA APPLICANTS: A person who files a claim with intent to defraud or helps commit a fraud
against an insurer is guilty of a crime.
NOTICE TO OHIO APPLICANTS: Any person who knowingly and with intent to defraud any insurance company 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.
NOTICE TO OKLAHOMA APPLICANTS: Any person who knowingly, and with intent to injure, defraud or deceive any
insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading infor-
mation is guilty of a felony.
FRAUD WARNING (Applicable in Tennessee, Virginia and Washington): It is a crime to knowingly provide false, in-
complete or misleading information to an insurance company for the purpose of defrauding the company. Penalties in-
clude imprisonment, fines and denial of insurance benefits.
NOTICE TO RHODE ISLAND APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment
of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be
subject to fines and confinement in prison.
GLS-APP-41s (7-12) Page 6 of 7
NOTICE TO NEW YORK APPLICANTS (Other than automobile): Any person who knowingly and with intent to defraud
any insurance company or other person files an application for insurance or statement of claim containing any materially
false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a
fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars
and the stated value of the claim for each such violation.
APPLICANT’S NAME AND TITLE:
APPLICANT’S SIGNATURE: DATE:
(Must be signed by an active owner, partner or executive officer)
PRODUCER’S SIGNATURE: DATE:
PRODUCER’S ADDRESS:
PRODUCER’S LICENSE NUMBER:
NAME AND PHONE NUMBER OF INDIVIDUAL TO CONTACT FOR INSPECTION/AUDIT:
IMPORTANT NOTICE
As part of our underwriting procedure, a routine inquiry may be made to obtain applicable information concerning
character, general reputation, personal characteristics and mode of living. Upon written request, additional information
as to the nature and scope of the report, if one is made, will be provided.
GLS-APP-41s (7-12) Page 7 of 7
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Halfway House General Liability Application (RT Specialty)

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Completed 13 December 2020

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