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RECOVERY RESIDENCE / SOBER LIVING HOME /TRANSITIONAL HOME (Philadelphia Insurance Companies)

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RECOVERY RESIDENCE / SOBER LIVING HOME /TRANSITIONAL
HOME APPLICATION
APPLICANT’S INFORMATION
SECTION I – GENERAL APPLICANT INFORMATION
1. Description of Operations: (select the dominate level of support)
Level 1: Peer Elected (low intensity, non-clinical)
Level 2: Senior Resident Peer manager (low service intensity, house manager, policies and procedures)
Level 3: Supervised (Facility manager, certified staff / case manager/ clinical services not provided in-house)
Level 4: Service Provider (Credentialed staff, clinical services and programming provide in-house)
2. Has the Applicant’s license ever been suspended, revoked, or placed under conditional status? Yes No
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, send a copy of the most current federal, state or agency complaint investigation report.
3. Has the Applicant had any insurance claims or lawsuits in the past five (5) years? Yes No
a. If yes, please provide the date, explanation and outcome:
4. Applicant’s approximate monthly Income: $
5. Total Number of beds: Total Building Area (square foot): Number of Stories:
6. What is the average occupancy: Average Length of Stay:
7. Resident age groups: Under 18: % 18 – 65: % Over 65: %
Male: % Female: % Co-Ed: %
How are the residents separated?
8. Is there a resident manager on premises? Yes No
9. Does the Applicant have written policies and procedures for tenants? Yes No
10. Are formal sign-in and sign-out procedures in place? Yes No
11. Does the Applicant control entrance and exit of residents? Yes No
12. Does the Applicant control entrance and exit of visitors? Yes No
13. Does the Applicant allow guests / visitors to stay overnight? Yes No
14. Does the Applicant have 24-hour supervision? Yes No
If yes, please describe:
15. Are there locks on the doors to sleeping areas? Yes No
16. Does the Applicant allow residents to keep pets on premises? Yes No
17.
State: Zip:
Applicant’s Name:
Address: City:
Website: Email Address:
FEIN:
Description of Operations:
Present Management:
Yes No
Non-Profit For Profit Number of Years: In Operation:
Is the Applicant’s organization more than 25% owned by a private equity fund structure?
If yes, provide name of private equity firm:
NAARAccreditations: Joint Commission CARF Other:
YesLicensed: No
Risk Management Contact:
Certified By:
Risk Management’s Phone:
Risk Management Email:
Recreation: (check all that apply)
Swimming Jacuzzi / Hot Tub Exercise Equipment
If any of the above were selected, please describe hours in use, supervision, and safety measures:
Recovery Residence / Sober Living Home/
Transitional Home Application
Page 1 of 6
© 2020 Philadelphia Consolidated Holding Corp.
07/2020
Clear Application
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18.
Aerobics and other aerobic activities
Horse Back Riding
Rock Climbing / Rappelling
Archery
Kayaking
Scuba
Baseball/softball/basketball/soccer
Motorized vehicles (ATVs, etc.)
Shooting Ranges
Bicycling
Obstacle Course(s)
Skiing
Football -- Flag / Tackle
Paintball
Snorkeling
Other:
Other:
Other:
19.
Please describe discharge policy:
SECTION II - AUTOMOBILE
1.
Does the Applicant provide transportation to tenants?
Yes
No
2.
Does the Applicant obtain MVR’s on all drivers?
Yes
No
3.
What are the Applicant’s procedures for dealing with drivers with accidents or violations?
4.
Does the Applicant allow tenants / clients to operate their vehicles?
Yes
No
5.
Does the Applicant’s employees transport tenants in their personal vehicles?
Yes
No
6.
Does the Applicant require employees and volunteers to carry and show evidence of personal
insurance?
Yes
No
If yes, what limits are required?
7.
Please provide a complete list of drivers. (NOTE: All drivers must have acceptable MVR’s)
8.
Explain the driver safety program:
9.
Estimated annual mileage of transportation provided:
Estimated annual transportation trips:
10.
Percentage of transportation is provided by:
Owned Autos:
%
Non-Owned Autos:
%
Hired Autos:
%
SECTION III – BUILDING INFORMATION
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.
Does the building have sprinklers?
Yes
No
If yes, areas 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
4.
Is cooking conducted on the premises?
Yes
No
If yes, is equipment:
Residential
Commercial
If commercial, are the installation, inspection and maintenance in accordance with the standards
and requirements of NFPA 96 standards?
Yes
No
5.
Does the building have emergency lighting?
Yes
No
6.
Does the building have fire alarms?
Yes
No
7.
Does the building have smoke detectors?
Yes
No
If yes:
Battery Operated
Hard-wired
8.
Does the building have Carbon Monoxide Detectors?
Yes
No
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?
Yes
No
11.
Are exit signs illuminated?
Yes
No
12.
Are fire drills held?
Yes
No
13.
Are there at least two exit doors per building?
Yes
No
14.
Are exit doors equipped with panic hardware?
Yes
No
15.
Are handrails on all ramps and steps?
Yes
No
16.
Is smoking permitted inside the building?
Yes
No
17.
Have all buildings built before 1971 been inspected for lead paint?
Yes
No
18.
Type of security provided:
Guards
Video Camera
Other:
Recovery Residence / Sober Living Home/
Transitional Home Application
Page 2 of 6
© 2020 Philadelphia Consolidated Holding Corp.
07/2020
Clear Application
Print Application
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
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
Adoptions
Foster Care
*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.
Recovery Residence / Sober Living Home/
Transitional Home Application
Page 3 of 6
© 2020 Philadelphia Consolidated Holding Corp.
07/2020
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5.
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.
6.
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.
7.
Is the Applicant aware of any circumstances which may result in any claim or suit, including request
for medical records? (If Yes, show all professional claims on a separate sheet)
Yes
No
8.
Does the Applicant’s psychiatrist, employed or contracted, prescribe experimental drugs or
treatment?
Yes
No
Recovery Residence / Sober Living Home/
Transitional Home Application
Page 4 of 6
© 2020 Philadelphia Consolidated Holding Corp.
07/2020
Clear Application
Print Application
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 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
monitoring, heat t
race, full insulation on piping or roof):
6.
General Comments:
Recovery Residence / Sober Living Home/
Transitional Home Application
Page 5 of 6
© 2020 Philadelphia Consolidated Holding Corp.
07/2020
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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, 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 VERMONT: ANY PERSON WHO KNOWINGLY PRESENTS A FALSE STATEMENT IN AN APPLICATION FOR INSURANCE MAY BE GUILTY
OF A CRIMINAL OFFENSE AND SUBJECT TO PENALTIES UNDER STATE LAW.
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.
NA
ME (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)
Recovery Residence / Sober Living Home/
Transitional Home Application
Page 6 of 6
© 2020 Philadelphia Consolidated Holding Corp.
07/2020
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RECOVERY RESIDENCE SOBER LIVING HOME TRANSITIONAL HOME (Philadelphia Insurance Companies)

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Completed 29 July 2020

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