Fillable MEDICAL EQUIPMENT SUPPLY STORES LIABILITY APPLICATION (Colonial General Insurance Agency, Inc)

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MEDICAL EQUIPMENT SUPPLY STORES LIABILITY APPLICATION (Colonial General Insurance Agency, Inc)

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GLS-APP-60s (9-16) Page 1 of 7
Scottsdale Insurance Company
Home Office: One Nationwide Plaza
Columbus, Ohio 43215
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
Scottsdale Surplus Lines Insurance Company
Adm. Office: 8877 North Gainey Center Drive
Scottsdale, Arizona 85258
MEDICAL EQUIPMENT SUPPLY STORES LIABILITY APPLICATION
Complete a separate application for each location.
Applicant’s Name:
Mailing Address:
Location Address:
Agency Name:
Agent No.:
Address:
E-mail:
Phone No.:
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” (N/A)
Applicant is: Individual Corporation Partnership Joint Venture
Limited Liability Company Other (Specify):
Website Address:
E-mail Address: Phone No.:
Limits Of Liability and Deductible Requested:
General Aggregate (other than Products/Completed Operations) $
Products and Completed Operations Aggregate $
Personal and 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 Ommissions Coverage Each Claim
(Must be equal to GL limits, subject to $1,000,000/$3,000,000 maximum.) Aggregate
$
$
Other Coverages, Restrictions, and/or Endorsements:
$
Deductible $
GLS-APP-60s (9-16) Page 2 of 7
1. Number of years in business: .................................................................................................................
2. Percentage of operations from sale of non-medical products, such as office furniture, printed
materials (e.g., labels, charts, prescription forms), scales, etc.: ....................................................................... %
3. Type of operation and annual sales:
Sale of Medical, Hospital and Surgical supplies ................................................................................... $
Rental/leasing of home care products/equipment to consumers .......................................................... $
Rent-to-own of home care products/equipment to consumers ............................................................. $
Drugstore/Pharmacy ............................................................................................................................. $
Provider of in-home services................................................................................................................. $
Describe:
Other ..................................................................................................................................................... $
Describe:
4. Additional Insured Information:
Name Address Interest
5. Provide breakdown of annual receipts:
Sales Rental Service
Expendable items (bandages, tape, gauze, dressing, etc.)
Non-expendable items (IV stands, traction apparatus,
walkers, crutches, surgical instruments [non-critical],
Prosthetic devices, etc.)
Retail Pharmaceuticals
Oxygen Equipment sales and rental (air compressors,
oxygen concentrators, oxygen [liquid], etc.)
Electric Wheelchairs and Scooters
Diagnostic or Treatment Devices (CT scanners, MRIs,
X-Ray equipment, EKG machines, IV pumps, blood
pressure gauges, etc.)
Ambulatory Equipment (manual wheelchairs, van lifts,
stair chair lifts, pool lifts, hand control devices, etc.)
Life Sustaining, Invasive or Critical Monitoring (Dialysis,
heart/lung machines, apnea monitors, ventilators, incuba-
tors, medical gas systems, life-function monitoring, etc.)
Home Infusion (distribution of drugs, nutrients,
chemotherapy, etc.)
6. Are Patrons fitted with rehabilitative items prescribed by doctors, such as back braces or neck
collars? ....................................................................................................................................................... Yes No
If yes, is the person doing the fitting an accredited surgical appliance technician? .................................... Yes No
7. Percentage of equipment sold or leased/rented which is physician prescribed: .............................. %
GLS-APP-60s (9-16) Page 3 of 7
8. Any sale of vitamins or nutritional supplements under applicant’s own label? ................................ Yes No
9. Any sale or rental of oxygen and/or respiratory equipment, such as oxygen concentrators, cyl-
inders and aspirators? .............................................................................................................................. Yes No
If yes, percentage of total operation: .......................................................................................................... %
Any refilling of oxygen (or other gases)? ..................................................................................................... Yes No
If yes, receipts: ............................................................................................................................................. $
10. Any sale or rental of any other gases? ................................................................................................... Yes No
If yes, describe:
11. Does applicant buy or sell used equipment? ......................................................................................... Yes No
Percentage of total operation: .................................................................................................................... %
If yes, does applicant recondition/repair, prior to resale? ............................................................................ Yes No
Does applicant sell “as is”? .......................................................................................................................... Yes No
Does applicant deliver equipment? ............................................................................................................. Yes No
If yes, how often?
12. Does applicant do any construction or installation? ............................................................................. Yes No
If yes, explain:
13. Any vehicle chair lift installation, service or repair? ............................................................................. Yes No
If yes, receipts: ............................................................................................................................................. $
14. Any repair or installation operations subcontracted? ........................................................................... Yes No
If yes, do you obtain Hold Harmless Agreements from your subcontractors? ............................................ Yes No
Minimum limits required of subcontractors: ................................................................................................. $
15. Is equipment maintenance performed and documented according to manufacturers
guidelines? ................................................................................................................................................. Yes No
16. Are customers given any applicable Material Data Safety Sheets prepared by the equipment
manufacturer? ............................................................................................................................................ Yes No
17. What are your procedures for reporting any malfunctioning devices to the Federal Drug Administration?
18. Sale, rental or leasing of any of the following equipment or machines? Indicate by “x.”
Anesthesia apparatus Intravenous Resuscitation equipment
Apnea monitors Kidney machines Scooters/Tricarts
Audiometers Laser medical devices Stair chair lifts
Beds, crutches, walkers, commodes Latex gloves Suction or Irrigation apparatus
Cardiac defibrillators Low air loss mattress TENS units
Diathermy machines Metal and foreign body locators Ventilators
Internal therapy Nebulizers Wheelchairs
EKG machines Oscilloscopes and monitoring devices Wheelchair lifts
Heart monitoring Parenteral therapy X-ray, fluoroscopy
Inhalation therapy machines Radiation therapy
GLS-APP-60s (9-16) Page 4 of 7
If you sell latex gloves, who manufactures them?
Where is the latex gloves manufacturer located?
Are the latex gloves purchased from a U.S. based distributor? .................................................................. Yes No
19. Does applicant directly import any foreign manufactured goods or equipment? ............................. Yes No
If yes, provide details:
20. Does applicant manufacture any goods or equipment? ....................................................................... Yes No
Do you manufacture orthopedic, ambulation or prosthetic devices? .......................................................... Yes No
If yes, provide details:
21. Does applicant employ or subcontract the services of any Respiratory Therapist or
Physician? .................................................................................................................................................. Yes No
Do you employ any certified professionals? ................................................................................................ Yes No
If yes, explain:
22. Are you a member of any Health Industry Association?....................................................................... Yes No
If yes, which (HIDA, JCAHCO, IMDA, other):
23. If a member of the Joint Commission on the Accreditation of Health Care Organizations, are
you Certified? ............................................................................................................................................. Yes No
If yes, attach copy of latest certification.
24. Any other premises or operations exposures not stated in this application? ................................... Yes No
If yes, attach a complete description and underwriting/rating information.
25. 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:
26. Does applicant have any other business ventures for which coverage is not required? ................. Yes No
If yes, explain and advise where insured:
27. During the past five years, have any claims been made or suits been brought against you be-
cause of alleged malpractice, error or mistake? .................................................................................... Yes No
If yes, date(s):
Please explain:
28. 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:
GLS-APP-60s (9-16) Page 5 of 7
29. Schedule Of Hazards:
Loc.
No.
Classification Description
Class.
Code
Exposure
Premium Basis
(s) Gross Sales
(p) Payroll
(a) Area
(c) Total Cost
(t) Other
30. Prior Carrier Information:
Year:
Year:
Year:
Year:
Year:
Carrier
Policy No.
Coverage
Occurrence or
Claims Made
Total Premium
31. 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.
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 AL, CO, DC, FL, KS, LA, ME, MD, MN, NE, NY,
OH, OK, OR, RI, TN, VA, VT or WA.)
NOTICE TO ALABAMA APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a
loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be
subject to restitution fines or confinement in prison, or any combination thereof.
GLS-APP-60s (9-16) Page 6 of 7
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 addi-
tion, an insurer may deny insurance benefits if false information materially related to a claim was provided by the appli-
cant.
NOTICE TO FLORIDA APPLICANTS: Any person who knowingly and with intent to injure, defraud, or deceive any insur-
er files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a fel-
ony of the third degree.
NOTICE TO KANSAS APPLICANTS: Any person who, knowingly and with intent to defraud, presents, causes to be pre-
sented 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 state-
ment 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 con-
ceals, 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 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 or willfully presents a false or fraudulent claim for
payment of a loss or benefit or who knowingly or 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, with intent to defraud or knowing that he is facilitating a fraud against
an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.
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.
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.
FRAUD WARNING (APPLICABLE IN VERMONT, NEBRASKA AND OREGON): Any person who intentionally presents
a materially false statement in an application for insurance may be guilty of a criminal offense and subject to penalties un-
der state law.
FRAUD WARNING (APPLICABLE IN 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. Penal-
ties include imprisonment, fines, and denial of insurance benefits.
GLS-APP-60s (9-16) Page 7 of 7
NEW YORK 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 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 STATEMENT:
I have read the above application and I declare that to the best of my knowledge and belief all of the foregoing statements
are true, and that these statements are offered as an inducement to us to issue the policy for which I am applying. (Kan-
sas: This does not constitute a warranty.)
APPLICANT’S SIGNATURE: DATE:
CO-APPLICANT’S SIGNATURE: DATE:
PRODUCER’S SIGNATURE: DATE:
AGENT NAME: AGENT LICENSE NUMBER:
(Applicable to Florida Agents Only)
IOWA LICENSED AGENT:
(Applicable in Iowa Only)
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.
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MEDICAL EQUIPMENT SUPPLY STORES LIABILITY APPLICATION (Colonial General Insurance Agency, Inc)

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Completed 22 August 2020

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