Fillable MENTAL HEALTH RENEWAL APPLICATION (Philadelphia Insurance Companies)

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MENTAL HEALTH RENEWAL APPLICATION (Philadelphia Insurance Companies)

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MENTAL HEALTH RENEWAL APPLICATION
Applicant’s Name:
Number of years under present management:
Annual Operating budget: $
Payroll: $
Risk Management Contact:
Risk Management’s Phone:
Risk Management Email:
1. Are any mergers planned/anticipated for the coming year? Yes No
If yes, please explain.
2. 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:
3. Does the Applicant provide integrated behavioral health and primary medical care services? Yes No
If yes, please describe your integrated care model.
4. Are any new programs or services planned/anticipated for the coming year? Yes No
If yes, please explain.
5. What is the staff turnover rate for the last 12 months?
6. Total number of clients:
7. What is the percentage of clients receiving addiction treatment services? %
8. Please provide the percentage of the age of clients served:
Client Percentage Client Percentage
Children (1 – 12) % Adults %
Teenagers % Geriatric (over 65) %
9. 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)
Mental Health Renewal
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Physical Therapist
Optician
Orthotics & Prosthetics (O&P)
Certified Practitioner
Counselor (Guidance,
Vocational)
Social Worker
Occupational Therapist
Speech Therapist
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
*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.
10.
Does the Applicant provide any foster care or adoption services?
Yes
No
If yes:
# of foster care children placed:
# of adoptions:
11.
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.
If the Physician, Psychiatrist, Dentist or Optician currently has medical professional coverage with the
company, the Applicant will not need to submit a newly completed medical professional application.
Please confirm names of medical professionals that are currently insured with company.
Name
Specialty
12
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.
13.
What is the staff-to-client ratio for each program?
Program
Staff
Clients
Ratio
13.
Is the Applicant aware of any circumstances which may result in any claim or suit, including
request for medical records?
Yes
No
Please describe all claims.
14. 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
Mental Health Renewal
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© 2019 Philadelphia Consolidated Holding Corp.
03/2019
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15.
Does the Applicant’s organization utilize GPS fleet telematics devices?
Yes
No
If yes, please check off the fleet telematics being utilized:
Plug in
Hard wired
Mobile Phone
Other:
16.
What percentage of the Applicant’s fleet is provided with these fleet telematics devices? %
MENTAL HEALTH FACILITIES PROVIDING ADDICTION TREATMENT SERVICES
ASAM Criteria Levels of Care
Level
Service Provided
%
Level
Service Provided
%
0.50 Early Intervention III.3
Clinically Managed Population
Special High Intensity
Residential Services
I Outpatient Services III.5
Clinically Managed High
Intensity Residential
II.I0 Intensive Outpatient III.7
Medically Monitored Intensive
Inpatient
II.50 Partial Hospitalization IV
Medically Managed Intensive
Inpatient
III.10
Clinically Managed Low
Intensity Residential
OTS Opioid Treatment Services
Client
Percentage
Male
%
Female
%
Previously participated in detox programs
%
Violent Offender
%
1.
What percentage of operations does this treatment represent? %
2.
If a methadone treatment program is provided:
a.
Is the Applicant’s program maintenance only, or do you offer methadone detox?
b.
Number of methadone-only clients annually:
c.
Number of clients with take home privileges:
d.
Describe measures to guard against the diversion of the methadone by employees and/or
clients:
3.
Does the Applicant provide other Medication Assisted Treatment (MAT)?
Yes
No
If yes, please provide the following:
a.
What percentage of operations does this treatment represent?
%
b.
Name of the medications administered:
c.
Total number of clients treated annually:
4.
Does the Applicant maintain all medications in a locked area?
Yes
No
5.
Do the Applicant’s intake procedures include a physical examination?
Yes
No
6.
Do the Applicant’s intake procedures include blood tests?
Yes
No
a.
If yes, are the blood tests used for any purpose outside of drug testing?
Yes
No
b.
If yes, please describe any other uses and possible disclosures from blood tests:
Mental Health Renewal
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© 2019 Philadelphia Consolidated Holding Corp.
03/2019
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7.
Do the Applicant’s services include a detoxification unit?
Yes
No
If yes, is it Social or Medical? Social Medical
If “Medical”, do you accept clients with a history of delirium tremens (DTs) or seizures?
Yes
No
If clients are experiencing DTs or seizures, do you treat them or refer them to a hospital?
Treat them Refer them to a hospital
If “Medical”, please provide breakdown in staffing during the first 72 hours
# of Physicians:
# of Nurse Practitioners:
# of RNs:
# of LPNs:
8.
Does the Applicant perform any “rapid detox” or any detox under general anesthesia?
Yes
No
9.
Does the Applicant’s program include providing services for Correctional Facilities?
Yes
No
a.
If yes, what percent of your overall operation: %
Mental Health Renewal
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© 2019 Philadelphia Consolidated Holding Corp.
03/2019
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WINTER WEATHER FREEZE-UP PROTECTION
1. Fire Protection and Testing
a. Is the building provided with an Automatic Fire Sprinkler System (AS)? Yes No N/A
i. If yes, approximately what percentage (%) of the building is sprinklered? %
ii. If yes, what type of sprinkler system is installed? Wet-Pipe Dry-Pipe Both
iii. If yes, when possible, is the sprinkler piping primarily run within conditioned
areas designed to ensure the temperature remains above the 45°F minimum
Yes No N/A
iv. If yes, is the testing & inspection by qualified sprinkler contractor completed
within past 12 months & includes a formal winterizati
on review?
Yes
No
N/A
v. If yes, are the alarms tied to a 24 hour UL listed monitoring company?
Yes
No
N/A
2. Emergency Water Response (domestic and AS water lines)
a. Are water shutoff valves (domestic and AS water lines) marked and readily
accessible?
Yes
No
N/A
b. Are water shutoff valves exercised (closed and reopened) at least annually?
Yes
No
N/A
c. Is the staff qualified to respond and shut off the water main during normal business
hours and off hours?
Yes
No
N/A
3. Automatic Water Shutoff Devices
a. For domestic water lines, is there a water flow detection, notification and automatic
shutoff?
Yes
No
N/A
4. Unused/Vacant Spaces
a. Does Applicant have a formal process to turn off and drain domestic water lines for
these spaces?
Yes
No
N/A
5. Unheated Areas (attics, crawl spaces, exterior wall joists)
a. Are all domestic water lines located in areas heated to at least 45°F?
Yes
No
N/A
i. If no, please describe freeze prevention measures (e.g. temperature monitoring,
heat trace, full insulation):
This section must be completed by all risks that have a location in one of the following states: AR, CT, DC, DE,
GA, IL, IN, KY, ME, MD, MA, MI, MO, NH, NY, NJ, NC, OH, PA, RI, SC, TN, TX, VT, VA, WV, WI
temperature?
1. If no, please describe freeze prevention measures (
e.g. temperature
m
onitoring, heat trace, full insulation on piping or roof):
6.
General Comments:
Mental Health Renewal
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© 2019 Philadelphia Consolidated Holding Corp.
03/2019
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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
SE
CTION 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)
Mental Health Renewal
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© 2019 Philadelphia Consolidated Holding Corp.
03/2019
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.
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 alle
ging 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
Print 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
SEC
TION 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
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MENTAL HEALTH RENEWAL APPLICATION (Philadelphia Insurance Companies)

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