Fillable Medical Facilities & Providers Application (CSRisks)

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Medical Facilities & Providers Application (CSRisks)

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A. ACCOUNT INFORMATION
onebeaconpro.com
MEDICAL FACILITIES AND PROVIDERS LIABILITY APPLICATION
877.701.0171 t
|
888.777.3719 f
199 Scott Swamp Road, Farmington, CT 06032
Homeland Insurance Company of New York
|
Homeland insurance Company of Delaware
(Stock companies owned by the OneBeacon Insurance Group)
Application
1. Applicant Name
Doing Business As
State of Domicile
2. Mailing Address
County: Website Address:
Federal Employee I.D. # (FEIN)
3. Risk Manager or
Contact Person
Name/Title:
Email Address:
Telephone Number:
4. Applicant’s Legal Structure
Individual
Corporation Partnership LLCJoint Venture
5. Tax Status For Prot — Private For Prot — Publicly Traded
6. Date Established
Not For Prot
7. List all States where the Applicant is operating and providing services:
City: State: Zip:
Street:
Instructions:
1. If the Applicant’s primary operation is an Ambulatory Surgery Center or an Urgent Care/ Walk-In Clinic, the Applicant must complete
the applicable Application below in place of this Application.
· Medical Facilities and Providers Ambulatory Surgery Center Application (HPA-30002-07-12)
· Medical Facilities and Providers Urgent Care and Walk In Clinic Application (HPA-30003-07-12)
2. If the Applicant performs or is requesting coverage for any of the following services, the Applicant must complete the applicable
Supplemental Application(s) and submit such Supplemental Application(s) with this Application.
· Ambulance Services (HPA-30006-07-12)
· Hired and Non-Owned Auto (HPA-30007-07-12)
· Imaging Center (HPA-30008-07-12)
· Medical Laboratory (HPA-30009-07-12)
· Neuromonitoring-Interoperative Services (HPA-30010-07-12)
· Non-Medical Professional Services (HPA-30011-07-12)
· Pharmacy Services (HPA-30012-07-12)
· Residential Care (HPA-30013-07-12)
· Schools (HPA-30014-07-12)
NOTICE: PORTIONS OF THE POLICY FOR WHICH THIS APPLICATION IS MADE MAY CONTAIN CLAIMS MADE AND REPORTED COVERAGE
WHICH APPLIES ONLY TO “CLAIMS” FIRST MADE AGAINST THE “INSURED” DURING THE “POLICY PERIOD” OR ANY APPLICABLE EXTENDED
REPORTED PERIOD AND REPORTED TO THE UNDERWRITER DURING THE “POLICY PERIOD” OR DURING ANY APPLICABLE EXTENDED
REPORTING PERIOD. PLEASE READ THE ENTIRE APPLICATION CAREFULLY BEFORE SIGNING.
HPA-30001-07-12 Page 1 of 12
10. List below all subsidiaries, description of operations, date acquired and ownership.
Name & Address
Description of Operations Relationship Date Acquired Ownership %
Retroactive
Date
11. Does the Applicant own, operate or manage any business or facilities other than the operations described in this
Application?
If “Yes,” please provide details, including name of entity and the Applicant’s ownership interest/management role.
(Please note that coverage for these entities is not automatically included. The policy, if issued, will determine coverage.)
12. List sources and amount of total revenue
Last 12 Months Next 12 Months (Projected)
a. Charitable Contributions
b. Government Funding
c. Fee for Service
e. Total Gross Revenues
13. Does the Applicant maintain any beds for overnight occupancy?
If “Yes,” please include the number of beds in the exposure section on the next page.
B. FINANCIAL AND EXPOSURE DETAILS
Yes No
Yes No
d. Other Income (Describe):
If “Yes,” describe the essential terms of such transaction.
9. Within the past 36 months or within the next 12 months, has the Applicant or does the Applicant expect to:
a. Merge, acquire or consolidate with another entity?
Yes No
b. Sell or divest another entity or facility?
Yes No
c. Discontinue any operations or services?
Yes No
d. Enter into any new business activities or services
(including new procedures or products being offered)?
Yes No
If “Yes,” please explain:
8. Is the Applicant owned by or controlled by another entity?
Yes No
HPA-30001-07-12 Page 2 of 12
Receipts
$
Ambulance
Ambulance - Air
Ambulance - Emergent (Ground)
Ambulance - Non-Emergent (Ground)
Clinical Trials/Research/Consulting
Pharmaceuticals
Medical Devices
Medical/Surgical Procedures
Day Care
Day Care - Adult Medical
Day Care - Pediatric Medical
Other (Describe):
Home Health/Hospice Care
Hospice Home Care
Home Health Infusion Therapy
Home Health Personal Care/Non Medical
Home Health Skilled Care
Home Health Rehabilitation
Hospice Care Facility
Inpatient
Imaging/X-Ray
Imaging - CT Scans
Imaging - MRI Facilities
Imaging - PET Scans
Imaging - X-Ray Diagnostic
Laboratory
Blood/Plasma Bank
Cardiac Catheterization Laboratory
Clinical Pathology Laboratory
Dental Laboratory
Medical Laboratory
Ocular Laboratory
Optical Establishment
Organ/Tissue Bank (Direct Processing)
Organ/Tissue Bank (No Direct Processing)
Quality Control/Reference Laboratory
Other (Describe):
Lithotripsy Centers
Lithotripsy Centers
Medical Staffing/Nurse Registry
Medical Staffing/Nurse Registry
Mental Health/Counseling
Mental Health/Counseling - Outpatient
Mental Health/Partial Hospitalization
Mental Health/Day Treatment Program
Pharmacy
Pharmacy - Compounding
Transfers Receipts
$
$
$
Receipts
$
$
$
Daily Census
Visits
Beds
Procedures Receipts
$
$
$
$
Pharmacy (continued)
Pharmacy - Infusion
Pharmacy - Remote Monitoring
Pharmacy - Retail
Pharmacy - Specialty
Rehabilitation
Cardiac Rehabilitation Center
Developmental Disability
Physical/Occupational Rehabilitation
Trauma Rehabilitation - Skilled Medical
Trauma Rehabilitation - Therapy
Residential Facilities
Adolescent/Child Residential Care
Apartments/Independent Living
Assisted Living
Group Homes
Halfway Houses/Shelters
School - Allied Medical Professional
Nursing/PT/OT
Physician Assistant, EMT, Paramedic
Optometry
Other Student Program:
Substance Abuse - Drug or Alcohol
Substance Abuse Counseling Outpatient
Substance Abuse - Detoxification
Substance Abuse - Residential
Substance Abuse - Skilled Medical
Substance Abuse Methadone Program
Treatment Centers
Cancer Treatment Center
College or University Health Center
Community Health Center
Crisis Stabilization Center
Dialysis Treatment Center
Health Department
Radiation Therapy
Other (Describe):
Sleep Center
Sleep Center
Telemedicine
Telemedicine
Teleradiology: Preliminary Reads
Teleradiology: Final Reads
Urgent Care/Urgicenter
Urgent Care/Urgicenter
Weight Loss Center
Weight Loss Center
Receipts
$
$
$
Receipts
$
$
$
$
$
$
$
$
$
$
$
Visits
Visits
# of Rx
Visits
Beds
# Faculty
# Students
Beds
Visits
Beds
Visits/Proc.
Beds
Visits
Patient Encounters
Visits
Visits
14. Instructions: Please provide projected exposure details for the next 12 Months for the Applicant and any subsidiaries or other entities
seeking coverage.
Visits - Count each patient each time they enter Applicant’s facility for healthcare related services. Beds - Use the total number of licensed
beds. Receipts - Use gross receipts. Do not adjust this gure for items such as prots, un-collectible accounts or amounts billed but not paid.
Receipts
$
Receipts
$
# of Rx
HPA-30001-07-12 Page 3 of 12
Receipts
$
15. Does the Applicant provide services to any of the following:
Correctional Facility
Hospital
Nursing Home, Assisted Living or other Residential Facility
Physician Ofces
Supplemental Stafng/Nurse Registry
Is training verified for all placed staff and matched for competency?
If “No,” please explain:
16. If staffing is provided to others, what percentage of Applicant’s total revenues is from staffing services?
Please indicate where staffing is provided (Percentage of revenues from staffing services):
% Pediatric
% Psychiatric
% Other
% Emergency Department
% Intensive Care Unit
% Medical Surgical Unit
% Neonatal
% Nursing Home /Assisted Living
% Obstetrical/Labor & Delivery
17. What percentage of the Applicant’s patients/clients are under 18 years of age? %
18. Does the Applicant:
c. Perform any surgical procedures?
19. Please provide information requested for each physician providing services at the Applicant’s facility:
Specialty Insurance Carrier/Policy Number/Policy Period
Hours Per
Month
Note: If coverage is requested for any physician, a supplemental application must be completed for each such physician.
Coverage for any physician is not automatically included. The policy, if issued, will determine coverage.
Physician Names Check One:
Specialty Insurance Carrier/Policy Number/Policy Period
Employee
Contractor
Hours Per
Month
Name of Medical Director Check One:
Employee
Contractor
Employee
Contractor
Employee
Contractor
Employee
Contractor
a. Prescribe medication to any patient?
b. Administer anesthesia (other than topical)?
If “Yes,” what percentage of procedures require general anesthesia %
Yes No
Yes No
Yes No
Yes No
d. Own any biomedical or other equipment used for diagnosis, monitoring or treatment purpose?
If “Yes,” do qualified personnel inspect and maintain the equipment on a regular basis?
Are manufacturers’ recommendations followed for all maintenance and repair of equipment?
Yes No
Yes No
Yes No
%
HPA-30001-07-12 Page 4 of 12
Number of: Annual Hours: Number of: Annual Hours: Number of:
Employees Contractors Volunteers
Annual Hours:
Addiction Counselor
Case Worker or Case Manager
Chiropractor
Dentist
EMT/Paramedic
Home Health Aide/Caregiver
Lab Technician
Mental Health Counselor
Nurse — RN
Nurse — LPN/LVN
Nurse Aide or Assistant
Nurse Anesthetist
Nurse Practitioner/Advance Practice Nurse
Occupational/Speech Therapist
Optometrist
Pharmacist
Physical Therapist
Physician
Physician Assistant
Podiatrist
Psychologist
Respiratory Therapist
Social Worker
Surgical Technician
Other:
20. Allied Health Care Professionals (Indicate number of personnel and annual hours worked in each applicable category)
21. Does the Applicant have any staff members who are not licensed or who have restricted licenses or
privileges?
If “Yes,” please explain:
22. Does the Applicant have written requirements that all clinical staff carry professional liability
insurance?
Indicate the minimum professional liability insurance limits required for employed or contracted:
a. Physicians or surgeons:
$ Each occurrence/$ Aggregate
b. Dentists, nurse anesthetists, nurse practitioners, physician assistants and nurse midwives
$ Each occurrence/$ Aggregate
c. Allied health care professionals:
$ Each occurrence/$ Aggregate
23. Does the Applicant verify staff professional liability insurance on an annual basis?
Yes No
Yes No
Yes No
HPA-30001-07-12 Page 5 of 12
Square
Footage
Age
Type of
Construction
Number of
Floors
Type of Fire Protection:
AS = Auto. Sprinkler; H = Heat Detector;
S = Smoke Detector; A = Auto. Alarm
Address/Occupancy
Please list all locations associated with the Applicant and provide corresponding premises information.
Medical Facilities Locations
Other Buildings
24. LIST OF LOCATIONS:
25. Does the Applicant sell or lease any medical equipment or products to patients or others in connection
with its operations?
If “Yes,” please complete the following information:
Total Annual Sales: $
Total Annual Lease/Rental Receipts: $
Category I. Expendable Items – Intended for one time usage and disposed (i.e. adhesive tape, bandages, or hypodermic needles, etc.)
Total Annual Sales: $
Total Annual Lease/Rental Receipts: $
Yes No
Category III. Diagnostic or treatment Devices – This category includes oxygen and other medical gases used in conjunction with respira-
tory therapy (excluding ventilators), treatment devices or equipment NOT used to sustain life or perform critical monitoring functions. Also
included are blood pressure gauges, I.V. pumps, portable EKG machines, or sending devices.
Total Annual Sales: $
Total Annual Lease/Rental Receipts: $
Category IV. Life Sustaining or Critical Life Monitoring Equipment or Devices – This category includes dialysis or heart/lung machines,
apnea monitors, or any other life dependent monitors or any other equipment or devices that if they malfunction/fail could result in death
or serious deterioration in a health condition.
Total Annual Sales: $
Total Annual Lease/Rental Receipts: $
Category II. Non-Expendable Items – Excluding diagnostic or treatment equipment or devices. This category includes, but is not limited to
hospital beds, bathroom safety bars, portable toilets, patient lifts or hoists, traction apparatus, ambulatory aids such as walkers, strollers,
canes, crutches, wheelchairs, etc. and prosthetic devices and I.V. stands including medical and surgical instruments unless considered diag-
nostic or treatment, etc.
Total Annual Sales: $
Total Annual Lease/Rental Receipts: $
GENERAL LIABILITY EXPOSURES: Complete this section (Questions 25-32) if General Liability Coverage is requested.
HPA-30001-07-12 Page 6 of 12
C. OPERATIONS AND ADMINISTRATION
26. Is the Applicant included as an additional insured under the applicable manufacturer’s Products Liability Coverage?
27. Have any of the products that the Applicant distributes been recalled?
If “Yes,” please provide details:
28. Does the Applicant have written procedures for examination and preserving any allegedly
defective equipment or product?
29. Does the Applicant provide preventive maintenance or repairs on medical equipment leased to others?
If “Yes,” please describe:
30. Does the Applicant repackage or redesign any products or equipment it sells, rents or leases?
If “Yes,” please describe:
31. Is any of the equipment or other products sold with the Applicant’s company label?
If “Yes,” please describe:
32. Does the Applicant have its own sales staff?
a. If “Yes,” are they trained by the manufacturer?
Please attach a copy of the Applicant’s policies on Sales Staff Training, Preventive Maintenance and Patient Education
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
33. Is the Applicant licensed in accordance with applicable state and federal regulations?
If “No,” please provide a detailed explanation:
34. Has the Applicant or other associated entity ever lost a license or been placed on probation by
any governmental licensing agency?
If “Yes,” please explain:
35. Is the Applicant a member of any professional organizations or associations?
If “Yes,” please list professional organizations or associations.
37. Does the Applicant have any contractual agreements with independent contractors who provide
services at its facility?
If “Yes,” please describe the services:
38. Are certificates of insurance obtained from all contracted providers evidencing liability limits
equal to or exceeding the Applicant’s liability limits?
39. Does the Applicant provide services to others on a contractual agreement?
If “Yes,” please describe the services and provide a copy of the contract:
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
36. Is accreditation by any governmental body or other quality/patient safety organization
available for the Applicant?
If “Yes,” please indicate accreditation(s) held:
Yes No
AAAHC CHAP JCAHOCLIA Other:
HPA-30001-07-12 Page 7 of 12
40. Does the Applicant agree to hold others harmless in any contractual agreement?
If “Yes,” please provide a copy of the contract.
41. Does Legal Counsel review all contractual agreements?
42. Is there a written, formalized Risk Management and/or Patient Safety Program?
43. Is there a system to document and report incidents, adverse events and complaints?
44. Are written policies and procedures in place for reporting of any suspected abuse?
Yes No
Yes No
Yes No
Yes No
Yes No
46. Are complete records kept on all patients or clients?
47. Is an Informed Consent process in place?
45. Has the Applicant had an incident at any facility that resulted in an allegation of sexual abuse
or molestation?
If “Yes,” please describe details of the incident(s).
50. Before staff can provide care, is a competency based checklist used to assess and document
their skills?
48. Please indicate all of the screening/hiring procedures used for professionals and others who
provide patient care services for Applicant’s operations:
a. Verification of educational background
b. Verification of previous employers/employment history
c.
Verification of personal references
f.
Verification of any pending license suspensions or revocations, or any pending disciplinary
actions by other facilities
g. Criminal background check: County
State Federal None
h. Require information on any professional liability or work related claims that have previously
been made against any individual
i. Require information on any allegations of sexual abuse or molestation previously
made against any individual
j. Drug/alcohol testing
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
49. Does the Applicant have written job descriptions?
Yes No
Yes No
d. Verification of hospital privileges for physicians and dentists
If “Yes,” how often does the Applicant update its list of specific privileges
HPA-30001-07-12 Page 8 of 12
51. Requested Effective
Date of Coverage
52. Requested Expiration
Date of Coverage
53. Coverage requested:
Professional Liability
Claims Made Occurrence
General Liability
55. Deductible Requested: (Deductible applies to each and every claim and applies to any combination of claim payments and claim expenses)
56. Is the Applicant currently enrolled in a Patient Compensation Fund?
57. Is the Applicant requesting to include Independent Contractors as Insureds?
54. Limits of Liability Requested (Each Claim/Aggregate):
Non Owned Automobile Liability Sublimit $
(Note: Non Owned and Hired Automobile Liability Supplemental Application must be completed)
Retroactive Date
(If Claims Made)
Retroactive Date
(If Claims Made)
Employee Benefit Administration Liability Retroactive Date
# of Employees
No Deductible $5,000 $10,000 $25,000 $50,000 $100,000 Other:
(Complete ACORD Application)Excess Limits:
$100,000/$300,000 $250,000/$750,000 $1,000,000/$3,000,000 $2,000,000/$4,000,000
$2,000,000/$6,000,000 Other:
Yes No
Yes
No
Claims Made Occurrence
Name & Address Interest
Coverage Desired
Please note that requested coverage is not automatically provided.
The policy, if issued, will determine actual coverage.
PL
GL
Description of Operations
58. Please describe any additional insureds to be included, their interest and requested coverage.
59. Provide the following information for Professional Liability Insurance and General Liability Insurance for
the current policy year and previous three years:
Policy Period Carrier Limits Ded/SIR CM or Occ
Retroactive
Date
Premium
PL
GL
PL
GL
HPA-30001-07-12 Page 9 of 12
F. REQUIRED INFORMATION
Please attach copies of the following documents to this Application. These documents shall be considered part of this Application.
• Currentlyvaluedlosshistoryforaminimumofthelast5yearsfromanyandallpreviouscarriers.Thelosshistoryshouldincludethe
current year and a breakdown of total incurred losses, paid losses and outstanding losses separated by year for all coverages being
requested;
• Mostcurrentauditedoraccountant-preparednancialstatementswithnotes;
• IfApplicantisnewlyformed,ProFormanancialstatements;
• Currentaccreditingagency(JCAHO,CARF,etc.)reportwithrecommendationsandthefacility’sresponsetoanycontingencies;
• CopyoftheApplicant’sRiskManagementandQualityImprovementPlan;
• CopiesofallmarketingoradvertisingbrochuresusedbyApplicant’sfacilities.
E. CLAIMS HISTORY
61. During the past ve (5) years, has any claim that would fall within the scope of the proposed insurance been
made against the Applicant or against any entity or individual proposed for coverage under this insurance?
If “Yes,” please provide dates of loss, claimant name, all defense and indemnity payments,
all defense and indemnity reserves (if claims are open), and claim status (open/closed):
NOTE: WITHOUT PREJUDICE TO ANY OTHER RIGHTS OR REMEDIES OF THE UNDERWRITER, IT IS AGREED THAT ANY CLAIM
REQUIRED TO BE DISCLOSED IN RESPONSE TO QUESTION 61 IS EXCLUDED FROM THE PROPOSED INSURANCE.
60. MISSOURI RESIDENTS - DO NOT ANSWER. Has any insurer canceled or declined to issue
Professional or General Liability insurance for the Applicant?
If “Yes,” please provide details:
Yes No
Yes No
62. Is the Applicant or any entity or individual proposed for coverage under this insurance aware of any fact,
circumstance, situation, transaction, event, act, error or omission which they have reason to believe may
or could reasonable be foreseen to give rise to a claim that may fall within the scope of the proposed
insurance?
If “Yes,” please provide details:
NOTE: WITHOUT PREJUDICE TO ANY OTHER RIGHTS OR REMEDIES OF THE UNDERWRITER, IT IS AGREED THAT ANY CLAIM
ARISING FROM ANY FACT, CIRCUMSTANCE, SITUATION, TRANSACTION, EVENT, ACT, ERROR OR OMISSION REQUIRED TO
BE DISCLOSED IN RESPONSE TO QUESTION 62 IS EXCLUDED FROM THE PROPOSED INSURANCE.
Yes No
HPA-30001-07-12 Page 10 of 12
G. FRAUD WARNINGS
Any person who knowingly and with intent to defraud any insurance company or another person, les an application for insurance con-
taining any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto, may
be guilty of committing a fraudulent insurance act, which is a crime and subjects the person to criminal and civil penalties.
NOTICE TO ALABAMA AND MARYLAND APPLICANTS: Any person who knowingly or willfully presents a false or fraudulent claim for pay-
ment of a loss or benet or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and
may be subject to nes and connement in prison.
NOTICE TO ARKANSAS, MINNESOTA, AND OHIO APPLICANTS: Any person who, with intent to defraud or knowing that he/she is facilitat-
ing a fraud against an insurer, submits an application or les a claim containing a false or deceptive statement is guilty of insurance
fraud, which is a crime.
NOTICE TO COLORADO APPLICANTS: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insur-
ance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, nes, 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 payable from insurance proceeds shall be reported to the Colorado division of insurance
within the department of regulatory agencies.
NOTICE TO DISTRICT OF COLUMBIA APPLICANTS: WARNING: 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 nes. In addition, an insurer may deny
insurance benets, 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 insurer les a statement of
claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.
NOTICE TO KENTUCKY APPLICANTS: Any person who knowingly and with intent to defraud any insurance company or other person les
an application for insurance containing any false information, or conceals for the purpose of misleading, information concerning any fact
material thereto, commits a fraudulent insurance act, which is a crime.
NOTICE TO LOUISIANA, NEW MEXICO AND RHODE ISLAND APPLICANTS: Any person who knowingly presents a false or fraudulent claim
for payment of a loss or benet or knowingly presents false information in an application for insurance is guilty of a crime and may be
subject to civil nes and criminal penalties.
NOTICE TO MAINE, TENNESSEE, VIRGINIA AND WASHINGTON APPLICANTS: It is a crime to knowingly provide false, incomplete or mis-
leading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, nes, or
a denial of insurance benets.
NOTICE TO NEW JERSEY APPLICANTS: Any person who includes any false or misleading information on an application for an insurance
policy is subject to criminal and civil penalties.
NOTICE TO OKLAHOMA APPLICANTS: WARNING: 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 information is guilty of a felony.
NOTICE TO OREGON AND TEXAS APPLICANTS: Any person who makes an intentional misstatement that is material to the risk may be
found guilty of insurance fraud by a court of law.
NOTICE TO PENNSYLVANIA APPLICANTS: Any person who knowingly and with intent to defraud any insurance company or other person
les an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of mis-
leading, 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 PUERTO RICO APPLICANTS: Any person who knowingly and with the intent to defraud, presents false information in an insur-
ance request form, or who presents, helps or has presented a fraudulent claim for the payment of a loss or other benet, or presents
more than one claim for the same damage or loss, will incur a felony, and upon conviction will be penalized for each violation with a ne
of no less than ve thousand dollars ($5,000) nor more than ten thousand dollars ($10,000); or imprisonment for a xed term of three
(3) years, or both penalties. If aggravated circumstances prevail, the xed established imprisonment may be increased to a maximum of
ve (5) years; if attenuating circumstances prevail, it may be reduced to a minimum of two (2) years.
HPA-30001-07-12 Page 11 of 12
H. SIGNATURE AND AUTHORIZATION
Produced By (Insurance Agent)
Insurance Agency
Insurance Agency Taxpayer ID
Agent License No. or Surplus Lines No.
Email Address
Address
City: State: Zip:
Street:
NOTE: FOr NEw HampsHirE applicaNTs, prOducEr’s NamE aNd sigNaTurE arE rEquirEd.
Submitted By (Insurance Agency)
Insurance Agency Taxpayer ID
Agent License No. or Surplus Lines No.
Address
City: State: Zip:
Street:
NOTE: This ApplicATiON musT bE sigNEd by A pARTNER, pRiNcipAl, diREcTOR OR OfficER Of ThE ApplicANT AcTiNg As ThE
AuThORizEd AgENT Of All iNdividuAls ANd ENTiTiEs pROpOsEd fOR This iNsuRANcE.
Applicant Name
By (Authorized Signature)
Name/Title
Date
The undersigned, as authorized agent of all individuals and entities proposed for this insurance, declares that, to the best of his/her knowledge and be-
lief, after reasonable inquiry, the statements in this Application and any attachments or information submitted with this Application (together referred to
as the “Application”) are true and complete. For Florida accounts, the preceding sentence is replaced with the following: The undersigned, as authorized
agent of all individuals and entities proposed for this insurance, represents that, to the best of his/her knowledge and belief, after reasonable inquiry,
the statements in this Application and any attachments or information submitted with this Application (together referred to as the “Application”) are
true and complete. The information in this Application is material to the risk accepted by us. If a policy is issued it will be in reliance upon the Applica-
tion, and the Application will be the basis of the contract.
We will maintain the information contained in and submitted with this Application on le and along with the Application will be considered physically
attached to, part of, and incorporated into the policy, if issued. For North Carolina, Utah and Wisconsin accounts, this Application and the materials
submitted with it shall become part of the policy, if issued, if attached to the policy at issuance.
We are authorized to make any inquiry in connection with this Application. Our acceptance of this Application or the making of any subsequent inquiry
does not bind you or us to complete the insurance or issue a policy.
The information provided in this Application is for underwriting purposes only and does not constitute notice to us under any policy of a Claim or poten-
tial Claim.
If the information in this Application materially changes prior to the effective date of the policy, you must notify us immediately and we may modify or
withdraw any quotation or agreement to bind insurance.
NOTICE TO NEW YORK APPLICANTS: Any person who knowingly and with intent to defraud any insurance company or other person les 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 ve thousand dol-
lars and the stated value of the claim for each such violation.
HPA-30001-07-12 Page 12 of 12
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Medical Facilities & Providers Application (CSRisks)

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Completed 19 July 2020

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