Fillable MENTAL HEALTH SUPPLEMENTAL APPLICATION (Philadelphia Insurance Companies)

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MENTAL HEALTH SUPPLEMENTAL APPLICATION (Philadelphia Insurance Companies)

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MENTAL HEALTH SUPPLEMENTAL APPLICATION
Pages 1 – 9 and the Fraud Statement must be completed by all Applicants
If you would like a quote for D & O and EPLI, please complete pages 11 & 12
Applicant’s name:
Website address:
Non Profit
For Profit
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:
Number of years:
In operation?
Accreditations:
JCAHO
CARF
COA
Other:
Risk Management Contact:
Phone Number:
Email:
REQUIREMENTS FOR SUBMISSION
• Completed ACORD Application(s)
• Currently valued insurance company loss runs for the
current policy period plus three (3) prior years
• Statement of Values
• Brochures and / or website information
• Copy of all current licenses
SECTION I – GENERAL APPLICANT INFORMATION
1.
Applicant’s annual operating budget: $
Applicant’s annual payroll: $
2.
Total number of clients:
Total number of methadone-only clients:
3.
Have there been any mergers or operations under another name within the past 5 years?
Yes
No
4.
Are any mergers or changes in operation anticipated?
Yes
No
If Applicant answered yes to either question #3 or #4 above, please explain on a separate sheet.
5.
Has the Applicant’s license ever been suspended, revoked, or placed under conditional status?
Yes
No
6.
a.
Have there been any claims that allege negligence or failure to comply with regulatory
standards?
Yes No
b.
Have there been any substantiated incidents?
Yes
No
If yes, please send a copy of the most current federal, state or agency complaint investigation report.
7.
Has the Applicant discontinued any programs in the past five years?
Yes
No
If yes, please explain:
8.
Facility director information:
Name:
Education level:
Number of years’ experience:
Number of years at this facility:
SECTION II – AGENCY SERVICES AND PROGRAMS
1.
Does the Applicant provide inpatient services?
Yes
No
If yes, please complete SECTION VII – RESIDENTIAL FACILITY
2.
Does the Applicant provide integrated behavioral health and primary medical care services?
Yes
No
If yes, please describe your program model:
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3.
Does the Applicant provide any of the following behavioral health services? (check all that apply)
Adoption*
%
Ex-Offender
%
Personality disorder
%
Adult day care
%
Family therapy
%
Post traumatic stress
%
Alzheimers
%
Fire starters
%
Public clinic
%
Anxiety disorder
%
Foster care*
%
Rape counseling
%
Attention deficit
%
For profit program
%
Schizophrenia
%
Autism
%
Home based Hotline
%
School based
%
Boot Camp
%
Jail diversion
%
Sexual aggression
%
Crisis stabilization
%
Juvenile justice
%
Sheltered Workshop
%
Correctional facility
%
Learning disorders
%
Shock therapy
%
Court designated
criminally insane
%
Lock Down Facility
%
Smoking cessation
%
Manic disorder
State hospitals/ institutions
Day care
%
Medication Assisted
Treatment
%
Other:
%
Depression
%
Methadone maintenance
%
Other:
%
Detoxification*
%
Mobile crisis
%
Eating disorders
%
Pedophile treatment
%
* If adoption, drug and alcohol or foster care services are provided, supplemental applications must be completed.
4.
What is the percentage of clients receiving addiction treatment services?
%
5.
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:
6.
Does the Applicant’s program include involuntary treatment (other than alcohol-related traffic
offenders)?
Yes
No
If yes, what % of your overall operation? %
7.
Does the Applicant provide or utilize telemedicine or telehealth services?
Yes
No
If yes, please provide the following:
a.
Complete description of the services:
b.
Include the names and qualifications of all health professionals involved
1)
2)
SECTION III – RISK ASSESSMENT
1.
Has the Applicant implemented an evidence-based program?
Yes
No
If yes, please provide the name of the program(s) you have implemented:
1.
2.
2.
Please provide the percentage of the age of clients served:
Client
Percentage
Client
Percentage
Children ( 1 – 12)
%
Adults
%
Teenagers
%
Geriatric (over 65)
%
3.
Does the Applicant’s organization have formal risk management guidelines for Applicant’s
practitioners to follow?
Yes
No
4.
Are the guidelines reviewed every two years?
Yes
No
5.
Does the Applicant’s staff receive job descriptions?
Yes
No
6.
Is formal training provided to staff?
Yes
No
7.
What is your de-escalation/physical restraint policy?
8.
During intake, are screening practices written and clearly communicated to all practitioners to
quickly identify how well the individual matches the organization’s services?
Yes
No
9.
Are written instructions and training provided to Applicant’s staff that:
a.
Identify urgent need?
Yes
No
b.
Ensure a prompt response to emergency situations?
Yes
No
% %
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c.
Provide timely initiation of services?
Yes
No
d.
Provide measurement and feedback to management?
Yes
No
10.
Do the Applicant’s intake procedures include a risk assessment that identifies specific
characteristics of the individual served for potential suicide?
Yes
No
11.
Have any of the Applicant’s clients attempted or committed suicide?
Yes
No
If yes, please indicate:
Year
# of clients
Year
# of clients
12.
Does the Applicant use a no suicide contract?
Yes
No
13.
Does the Applicant administer medications?
Yes
No
If yes, please complete the following questions:
a.
At the time the individual enters the Applicant’s organization, is a complete list of medications
he or she is taking created and documented?
Yes
No
b.
At the time the individual is transferred within or outside the Applicant’s organization, does the
current provider inform and document the receiving provider about the medication list?
Yes
No
c.
At the time an individual leaves the Applicant’s organization, is a current list of medications
provided and explained to the individual, family and the individual’s primary care provider?
Yes
No
14.
Does the Applicant’s risk management program include instructions for medical record
documentation?
Yes
No
If yes, is there a quality improvement program in place to monitor the documentation?
Yes
No
15.
Does Applicant use electric shock treatment?
Yes
No
16.
Are written agreements in place with independent contractors?
Yes
No
17.
Are certificates of liability insurance obtained and maintained for all contracted service providers
/independent contractors?
Yes
No
Please indicate the limit of liability required: $
18.
Does the Applicant operate a medical clinic?
Yes
No
If yes, is it open to the public?
Yes
No
19.
Does Applicant sponsor any fund raising activities?
Yes
No
If yes, on a separate sheet please provide a list with a description of each.
SECTION IV – PROFESSIONAL LIABILITY
1.
Does the Applicant’s current insurance program include coverage for Professional Liability?
Yes
No
If yes, please provide carrier information.
2.
Prior carrier:
Company
Limits of
Liability
Effective
Dates
Annual
Premium
Claims Made
or Occurrence
Retroactive Date
(Claims Made Only)
$
$
$
$
3.
Has any company declined, canceled or refused to renew any of the Applicant’s Professional
Liability insurance?
Yes
No
4.
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
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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
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.
5.
Does the Applicant provide any foster care or adoption services?
Yes
No
If yes:
# of foster care children placed:
# of adoptions:
6.
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.
7.
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 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.
8.
Is the Applicant aware of any circumstances which may result in any claim or suit, including request
for medical records?
Yes
No
On a separate sheet, show all professional claims.
9.
Does the Applicant’s psychiatrist, employed or contracted, prescribe experimental drugs or
treatment?
Yes
No
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SECTION V – HIRING AND SCREENING
1.
Check methods used for all employees, independent contractors or volunteers:
Criminal Background Checks Federal State
Validate Driver’s License
Drug Testing
Validate Education
MVR
Validate Personal Auto Insurance and Limits
Personal Interview
Validate Work History
Reference Checks
Verification of current certification/professional license
Sexual Abuse Registry
Other:
2.
How are references checked?
Written
Verbal
Both
3.
Are all methods completed before an offer of employment is made?
Yes
No
4.
Does the applicant have a formal volunteer program?
Yes
No
5.
Does the Applicant verify if potential employees and individual contractors have ever had their
license revoked or suspended, or disciplinary action taken against them?
Yes
No
6.
What is the staff turnover rate?
SECTION VI – BUILDING INFORMATION
N/A
(Please complete for each location)
1.
Does the property have aluminum wiring?
Yes
No
If yes, has it been retrofitted by a licensed electrician?
Yes
No
Indicate which method:
COPALUM crimp
AlumniConn
CO/ALR Devices
Pigtailed
2.
Sprinklers?
Yes
No
If yes, area of coverage:
3.
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
SECTION VII – RESIDENTIAL FACILITY
N/A
(Please complete for each residential facility)
Facility address:
Licensed capacity - number of beds:
# of stories:
Year built:
1.
Type of facility:
Alcohol / drug abuse
Developmental disabled
Mental health
Supervised living
Assisted living
Hospice
Nursing home
Transitional
Boarding/rooming house
Lock down facility
State hospital/Institution
2.
Referral Source:
Case manager
Extended care facility
Mobile crisis unit
Other:
Community agencies
Hospital
Physicians office
Other:
Court ordered
Hotline
Suicide Intervention
4. Commercial Is cooking conducted on the premises? Yes No If yes, is equipment: Residential
If commercial, are the installation, inspection and maintenance in accordance with the standards
and requirements of NFPA 96 standards? Yes No
5. Are swimming pools located on the premises? Yes No
If yes, are all swimming pools & spas compliant with Virginia Graeme Baker Pool & Spa Safety Act? Yes No
6. Emergency lighting? Yes No
7. Fire alarms? Yes No
8. Smoke Detectors? Yes No If yes: Battery operated Hard wired
9. Are evacuation routes posted throughout the building? Yes No
10. In the event of an evacuation, has a central meeting point outside the building been established? No
11. Are exit signs illuminated? No
12. Are fire drills held? No
13. Are there at least two exit doors per building? No
14. Are exit doors equipped with panic hardware? No
15. Are handrails on all ramps and steps? No
16. Is smoking permitted inside the building? No
17. Have all buildings built before 1971 been inspected for lead paint?
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes No
18. Type of security provided: Guards Video Camera Other:
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3.
Are residents screened by a physician prior to admission?
Yes
No
If no, on a separate sheet please describe the procedure that determines who is eligible for admission.
4.
Resident age groups:
Infant: %
Under 18: %
18 – 65: %
Over 65: %
Male
Female
Co-ed
How are residents separated?
5.
Number of beds:
Average occupancy:
Average length of stay?
6.
Number of non-ambulatory clients:
7.
Are resident’s rooms located on the ground floor?
Yes
No
8.
Are formal sign-in and sign-out procedures in place?
Yes
No
9.
On a separate sheet, please describe discharge policy.
10.
What is the staff-to-client ratio for each program?
Program
Staff
Clients
11.
What is the staff turnover for the last 18 months?
12.
Has the Applicant developed written procedures for a standardized “handoff” process to ensure
accurate communication of essential elements of care between shift changes?
Yes
No
13.
What is your de-escalation/physical restraint policy?
14.
Bed check procedures:
a.
Time intervals:
b.
Qualifications of staff performing:
c.
Documentation procedures:
d.
Video surveillance:
Yes
No
15.
Water heater temperature setting:
Are anti-scald devices installed?
Yes
No
SECTION VIII – ABUSE AND MOLESTATION
1.
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 offense, before an offer of
employment is made?
Yes
No
2.
Does the Applicant have a plan of supervision that monitors staff in day-to-day relationships with
clients both on and off premises?
Yes
No
3.
Has the Applicant’s organization ever had an incident which resulted in an allegation of sexual
abuse?
Yes
No
a.
Was a claim made against the organization?
Yes
No
b.
Was a claim made against any employee?
Yes
No
If yes, is that individual still employed with the Applicant’s organization?
Yes
No
c.
Was the case settled?
Yes
No
d.
What changes were made to prevent reoccurrence?
On a separate sheet, please describe all claims.
4.
Does the Applicant have written abuse and molestation procedures and are they clearly
communicated to all employees, independent contractors and volunteers?
Yes
No
5.
Does the Applicant’s current insurance program include coverage for Abuse and Molestation?
Yes
No
If yes, please provide carrier information.
6.
Prior carrier:
Company
Limits of
Liability
Effective
Dates
Annual
Premium
Claims Made
or Occurrence
Retroactive Date
(Claims Made Only)
$
$
$
$
SECTION IX - AUTOMOBILE
1.
Are all vehicles listed on the ACORD application titled to the applicant?
Yes
No
If no, explain:
2.
Where does the Applicant keep own vehicles?
Garage
Driveway
Parking Lot
Other:
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3.
Are keys locked and secured away from non-drivers when not in use?
Yes
No
4.
Are vehicles with eight or more seating capacity equipped with an audible backup warning device?
Yes
No
5.
Does the Applicant provide pickup or delivery of donated merchandise?
Yes
No
6.
Does the Applicant provide transportation for:
Staff
Clients/Residents
Visitors/Public
Meals
If yes for clients / residents, is more than one staff member required in the vehicle?
Yes
No
If yes for meals, what precautions does the Applicant take to prevent food spoilage?
7.
Does the Applicant transport clients / residents for other private or government agencies?
Yes
No
If yes, explain:
If yes, for a fee?
Yes
No
8.
Does the Applicant provide transportation for field trips?
Yes
No
If the Applicant does not provide the transportation, how is it provided?
If vehicles are hired for field trips, are they hired with a driver?
Yes
No
9.
If children are transported, is there a monitor to ensure their safety during transportation?
Yes
No
10.
Do the Applicant’s employees/volunteers transport children in their own vehicles?
Yes
No
If yes, how often?
11.
Are vehicles checked after passengers disembark to make sure no one is left behind?
Yes
No
12.
Do vehicles equipped for wheelchairs have tie-down belts to stabilize the wheelchair and
passenger?
Yes No
13.
Does the Applicant require seat belts to be worn by all occupants?
Yes
No
14.
Does the Applicant have a vehicle maintenance program in place?
Yes
No
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? %
SECTION X - DRIVERS
N/A
1.
Does the Applicant obtain a written authorization to release driver information from all of staff upon
hiring?
Yes
No
Does the Applicant obtain MVRs on all drivers?
Yes
No
If yes, how often?
2.
What are the Applicant’s procedures for dealing with driver accidents or violations?
3.
Are all drivers at least 21 years of age?
Yes
No
4.
How many drivers (employees and volunteers) aged 21 to 25 transport clients in agency vehicles?
5.
Do any drivers have a Commercial Driver’s License?
Yes
No
6.
Explain the Applicant’s driver safety program:
7.
Is training provided for new employees/volunteers prior to their transporting clients?
Yes
No
If yes, explain:
8.
Does anyone besides employees or volunteers drive the Applicant’s vehicles?
Yes
No
If yes, explain:
9.
Does the Applicant allow personal use of the Applicant’s vehicles?
Yes
No
If yes, by whom and for what reasons?
SECTION XI – HIRED AND NON-OWNED VEHICLES
N/A
1.
Does the Applicant hire vehicles?
Yes
No
If yes, what types of vehicles does the Applicant hire?
Does the Applicant obtain certificates of insurance?
Yes
No
What minimum limits does the Applicant require? $
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2.
Does the Applicant hire from a transportation company?
Yes
No
If yes, with drivers?
Yes
No
3.
Total number of hired vehicles:
Annual cost of hire: $
4.
How many drive personal vehicles for business use regularly?
F/T:
P/T:
Vol:
How many drive personal vehicles for business use occasionally?
F/T:
P/T:
Vol:
Does the Applicant obtain proof of insurance for employees/volunteers who use their own autos?
Yes
No
Does the Applicant update these records at least yearly?
Yes
No
What minimum limits does the Applicant require? $
SECTION XII – CLAIMS MADE
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:
SECTION XIII – 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 Offenders
%
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1.
If a methadone treatment program is provided:
a.
What percentage of operations does this treatment represent?
%
b.
Is the Applicant’s program maintenance only, or do you offer methadone detox?
c.
Number of methadone-only clients annually:
d.
Number of clients with take home privileges:
e.
Describe measures to guard against the diversion of the methadone by employees and/or
clients:
2.
Does the Applicant maintain all medications in a locked area?
Yes
No
3.
Do the Applicant’s intake procedures include a physical examination?
Yes
No
4.
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:
5.
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:
6.
Does the Applicant perform any “rapid detox” or any detox under general anesthesia?
Yes
No
7.
Does the Applicant’s program include providing services for Correctional Facilities?
Yes
No
a.
If yes, what percent of your overall operation: %
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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 winterization r
eview?
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
monit
oring, heat trace, full insulation on piping or roof):
6.
General Comments:
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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
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)
Mental Health Supplemental
Page 11 of 15
© 2019 Philadelphia Consolidated Holding Corp.
03/2019
Clear Application
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DIRECTORS & OFFICERS / EMPLOYMENT PRACTICE LIABILITY
THIS SECTION IS AN APPLICATION FOR A CLAIMS MADE POLICY.
PLEASE READ YOUR POLICY CAREFULLY.
DIRECTORS & OFFICERS LIABILITY INFORMATION
1.
Does the Applicant have a tax-exempt status under the U.S. Internal Revenue Code?
Yes
No
If no, provide an explanation:
2.
FINANCIAL INFORMATION
CURRENT FISCAL YEAR
PREVIOUS FISCAL YEAR
Total Assets:
$
$
Net Assets / Fund Balance:
$
$
Annual Revenue:
$
$
Net Revenue:
$
$
3.
Provide a list of all direct and indirect subsidiaries or any other entity or organization the Applicant controls:
Name / Type of Business
Percent the Applicant
Owns/Controls
Date Created /
Acquired
For Profit / Non-
Profit
I.E.: ABC Foundation / Charitable
Foundation
100%
01/01/2000
Non-Profit
%
%
%
Additional entities listed by attachment
4.
Has the Applicant or any person proposed for coverage herein been the subject of, or involved in,
any of the following in the past five (5) years? If yes, please attach details.
Yes
No
Any disciplinary action by any regulatory agency or association?
Yes
No
Any administrative proceeding charging violation of a federal or state law or regulation?
Yes
No
Any other criminal actions?
Yes
No
5.
In the past 24 or next 12 months has the Applicant been, or anticipate being involved in any merger,
acquisitions or consolidation with another entity?
Yes
No
If yes, please attach details.
EMPLOYMENT PRACTICE LIABILITY INFORMATION:
1.
Please provide the following employee count information:
U.S. based employees:
Total Full-Time:
Total Part-Time:
Volunteers:
Temporary:
Leased:
Total Non U.S. based employees:
TOTAL SUM OF ABOVE:
2.
Has a reduction in employees or change in of status occurred in the past 12 months or is anticipated
in the next 12 months?
Voluntary:
Involuntary:
Layoffs:
3.
Does the Applicant have an employment handbook that includes an “At Will” statement?
Yes
No
4.
Does the Applicant use an employment application for every potential employee?
Yes
No
Mental Health Supplemental
Page 12 of 15
© 2019 Philadelphia Consolidated Holding Corp.
03/2019
Clear Application
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5.
Does the Applicant use outside employment counsel for employment advice?
Yes
No
6.
Does the Applicant have a full time, dedicated human resource staff?
Yes
No
7.
Total number of current employees with annual compensation greater than $100,000:
CURRENT COVERAGE:
COVERAGES
Insurance Company
Limit of
Liability
Deductible
Policy Effective
Dates
Premium
D & O
$
$
$
EPLI
$
$
$
Fiduciary
$
$
$
Workplace
Violence
$
$
$
Internet Liability
$
$
$
WARRANTY INFORMATION:
1.
With respect to this coverage, has any Underwriter refused, canceled or non-renewed coverage?
(Not Applicable in Missouri)
Yes
No
If yes, please provide details:
2.
Has the Applicant given written notice under the provisions of any prior policies providing similar
insurance or claims, or of specific facts or circumstances which might give rise to a claim being
made against any person or entity applying for this insurance?
If yes, complete a Claim Supplemental for each incident.
Yes
No
3.
No person applying for this coverage is aware of any facts or circumstances which he or she has
reason to suppose might give rise to a future claim that would fall within the scope of any of the
proposed coverages for which the Applicant has applied, except: None or as noted below.
With regard to questions 2. and 3., it is understood and agreed that if any such claim, act, error, omission,
dispute or circumstance exists, then such claim and/or claims arising from such act, error, omission, dispute or
circumstance is excluded from coverage
that may be provided under this proposed insurance and, further,
failure to disclose such claim, act, e rror, omission, dispute or circumstance may result in the proposed
insurance being void, and/or subject to rescission.
Mental Health Supplemental
Page 13 of 15
© 2019 Philadelphia Consolidated Holding Corp.
03/2019
Clear Application
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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
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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
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)
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MENTAL HEALTH SUPPLEMENTAL APPLICATION (Philadelphia Insurance Companies)

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Completed 29 July 2020

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