Fillable RENEWAL AH HOME HEALTH And MEDICAL STAFFING Final (Kinsale Insurance)

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RENEWAL AH HOME HEALTH And MEDICAL STAFFING Final (Kinsale Insurance)

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The RENEWAL AH HOME HEALTH And MEDICAL STAFFING Final (Kinsale Insurance) form is 7 pages long and contains:

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  • 39 check-boxes
  • 189 other fields

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Page 1 of 7
RENEWAL APPLICATION FOR HOME HEALTH AND STAFFING
Instructions to the Applicant – please complete this application in ink and answer all questions completely. Attach extra
sheets as necessary should you run out of space provided. An incomplete or illegible application cannot be processed.
Completion of this application neither binds coverage nor guarantees that a policy will be issued.
• Provide a fully completed application, signed and dated by the owner, partner, or officer not earlier than 45 days
before the proposed effective date of coverage.
• If a question is not applicable, then state “N/A”.
1. Full name of Applicant (Including DBA’s) ___________________________________________________________________
2. Current Kinsale Policy Number: ________________________________________
5. Inspection/Risk Management Contact Name:
6. Inspection/Risk Management Contact E-mail:
7.
Please check the category which best describes your organization (check all that apply) :
Home Health Care
____%
of overall services*
Medical Staffing
____%
of overall services*
*If the insured provides Home Health and Staffing services, please note the percentage split between operations. (Total
must equal 100%)
3. MAILING ADDRESS: __________________________________________________________________________________
STREET CITY COUNTY STATE ZIP
4. LOCATION ADDRESSES: - Check here if no changes OR indicate all current locations below
(1) ________________________________________________________________________________________
STREET CITY COUNTY STATE ZIP
(2) ________________________________________________________________________________________
STREET CITY COUNTY STATE ZIP
(3) ________________________________________________________________________________________
STREET CITY COUNTY STATE ZIP
(4) ________________________________________________________________________________________
STREET CITY COUNTY STATE ZIP
GENERAL INFORMATION
OPERATIONS
Kinsale Insurance Company
P. O. Box 17008
Richmond, VA 23226
(804) 289-1300
www.kinsaleins.com
Page 2 of 7
8.
Please state sources and amounts of total revenue and patient contacts:
REVENUES / SALES
Source:
Charitable contributions
Government Funding
Fee for services
Other – specify _________________
TOTAL GROSS REVENUES
LAST 12 months
$________________
$________________
$________________
$________________
$________________
$________________
$________________
$________________
$________________
$________________
9.
Please indicate percentage of time spent in the following work locations:
10. Percentage of Types of Services Provided (total must equal 100%)
Personal Care Chore or Companion
______%
Respiratory Therapy
______%
Rehabilitation
– including PT, OT, ST
______%
Radiation Therapy
______%
Infusion Therapy
______%
Skilled Nursing Care
______%
Hospice – In Home
______%
Pediatric Care
______%
Chemotherapy
______%
Medical Equipment Supplier
______%
Skin Care or Bedsore Wound Care
______%
In Home Dialysis
______%
Other: ________________________
______%
Other: ________________________
______%
Private Home
______%
*Hospital Based Staffing
(only if hospital is noted)
Assisted Living
______%
Operating Room
______%
Nursing Home
______%
Emergency Room
______%
Institutional Hospice
______%
Labor & Delivery
______%
Ambulatory Surgery Center
______%
Neonatal (NICU)
______%
Adult Day Care
______%
Adult Intensive Care Unit
______%
Clinic
______%
Pediatric Intensive Care Unit
______%
Physician’s Office
______%
Other Hospital
(specify where)
______________________
______%
Correctional / Prison /Jail
______%
Hospital
* complete table on right
______%
Other (specify where)
______________________
______%
11.
Have there been any other major changes in exposures (acquisitions, new or discontinued procedures
or services, etc) which are not reflected above? If yes, please provide details.
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
YES NO
Page 3 of 7
12. Please indicate the current number of employed and contracted staff:
Type of Health Care Provider
# of
Employees
Annual
Employee
Hours Worked
# of
Independent
Contractors
Annual
Contractors
Hours Worked
Personal Companion/ Homemaker
Live In Companions
Certified Nurse Aid (CNA)
Licensed Practical Nurse (LPN)
Registered Nurse (RN)
Medical Technician
Nurse Practitioner
Speech Therapist
Occupational Therapist
Physical Therapist
Social Worker
Physician Assistant
CRNA
Nurse Midwife
Physicians (all types)
Other:
Other
14. TYPE OF EQUIPMENT SOLD OR RENTED (complete table below)
13. Please provide the name and specialty of the applicant’s Medical Director: ________________________________________
Full Time or Part Time
Does the applicant’s Medical Director have direct patient care? YES NO
SALES REVENUE RENTAL REVENUE
CATEGORY I.
EXPENDABLE ITEMS – intended for one time usage and disposed (ie
adhesive tape, bandages, hypodermic needles, etc.)
$_________________ $_________________
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, lifts, or hoists, walkers, strollers,
canes, crutches, wheelchairs, etc.
$_________________ $_________________
CATEGORY III.
DIAGNOSTIC OR TREATMENT DEVICES – This category includes oxygen and
other medical gases used in conjunction with respitory therapy (excluding
ventilators), treatment devices or equipment not used to sustain life or
perform critical life monitoring functions. Also include are blood pressure
gauges, IV pump, portable EKG machines or sending devices.
$_________________ $_________________
CATEGORY IV.
LIFE SUSTAINING OR CRITICAL LIFE MONITORING EQUIPMENT OR DEVICES
– this category includes dialysis or heart/lung machines, apnea monitors,
SIDS monitors or any other life dependent monitors or any other equipment
or devices that malfunction/failure or improper function could result in
death or serious deterioration in health condition.
$_________________ $_________________
STAFF
MEDICAL EQUIPMENT or SUPPLIES – RENTAL OR SALES - Complete ONLY if you have these operations (12&13)
Page 4 of 7
CLAIMS HISTORY -Provide details for all “Yes” answers to questions 14-19 as noted - attach additional pages as needed
15.
Does the applicant REPAIR or PERFORM MAINTENANCE on any medical supplies and/or equipment?
1. If “yes” please advise the total Annual Sales: ___________________
2. Types of equipment serviced?
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Yes No
16. In the last 12 months, has the applicant or any of its employees ever had any professional license or
license to prescribe and or dispense narcotics ever been limited, suspended, revoked, denied, or
investigated by any licensing board or regulatory agency? Explain below or attach additional pages as
needed.
YES NO
17. In the last 12 months, has the applicant or any of its employees ever been charged with, or convicted of
a crime other than minor traffic violations? Explain on below or attach additional pages as needed.
YES NO
18. In the last 12 months, has the applicant or any of its employees ever been diagnosed or treated for
alcoholism, drug addiction, any chemical dependency, or mental or chronic physical illness? Explain on
below or attach additional pages as needed.
YES NO
19. In the last 12 months, has any claim or suit for malpractice or professional liability ever been made
against the applicant OR any other person proposed for this insurance (to include any reports to
previous carriers)? How Many? ______ (Complete Supplemental Claims form for Each.)
YES NO
20.
Is the Applicant or any person proposed for this insurance aware of any act, error, omission, fact,
circumstance, or records request from any attorney which may result in a malpractice claim or suit?
If yes, please explain in detail, completing a supplemental claim form for each.
YES NO
21.
Has any claim or suit for malpractice ever been made against the Applicant or any person proposed for
this insurance that has not been reported to the Applicant’s current or prior insurer?
If yes, please
explain in detail, completing a supplemental claim form for each.
YES NO
SUPPLEMENTAL INFORMATION Use the remainder of this page as needed or to address questions referenced within the application
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Page 5 of 7
NOTICE TO ALABAMA, ALASKA, ARIZONA, ARKANSAS, CALIFORNIA, CONNECTICUT, DELAWARE, GEORGIA, IDAHO, ILLINOIS, INDIANA, IOWA, KANSAS, MARYLAND,
MASSACHUSETTS, MICHIGAN, MINNESOTA, MISSISSIPPI, MISSOURI, MONTANA, NEBRASKA, NEVADA, NEW HAMPSHIRE, NORTH CAROLINA, NORTH DAKOTA,
OREGON, RHODE ISLAND, SOUTH CAROLINA, SOUTH DAKOTA, TEXAS, UTAH, VERMONT, WASHINGTON, WEST VIRGINIA, WISCONSIN, AND WYOMING
APPLICANTS: In some states, 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, for the purpose of misleading, conceals information concerning any fact material thereto, may
commit a fraudulent insurance act which is a crime in many states.
NOTICE TO COLORADO APPLICANTS: 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 policy holder or claimant for the
purpose of defrauding or attempting to defraud the policyholder or claiming with regard to a settlement or award payable for 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 fines. In addition, an insurer may deny insurance benefits 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 insurance company files a statement of claim
containing any false, incomplete or misleading information is guilty of a felony of the third degree.
NOTICE TO HAWAII APPLICANTS: For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or benefit is a
crime punishable by fines or imprisonment, or both.
NOTICE TO KENTUCKY APPLICANTS: 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.
NOTICE TO LOUISIANA APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false
information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
NOTICE TO MAINE APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of
defrauding the company. Penalties may include imprisonment, fines, or denial of insurance benefits.
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 NEW MEXICO APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false
information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties.
NOTICE TO NEW YORK APPLICANTS: Any person who knowingly and with intent to defraud an insurance company or other person files an application for insurance
or statement of claim containing any materially false information, or conceals, for the purpose of misleading, information concerning any fact material thereto,
commits a fraudulent insurance act, which is a crime and shall also be subject to a civil penalty not to exceed $5,000 and the stated value of the claim for each such
violation.
NOTICE TO OHIO APPLICANTS: Any person who, with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an application or files
a claim containing a false or deceptive statement is guilty of insurance fraud.
NOTICE TO OKLAHOMA APPLICANTS: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes a any claim for the
proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.
NOTICE TO PENNSYLVANIA APPLICANTS: Any person who knowingly and with intent to defraud any insurance company, or other person, files an application for
insurance or statement of a 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 the person to criminal and civil penalties.
NOTICE TO TENNESSEE APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of
defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.
NOTICE TO VIRGINIA APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of
defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.
The Applicant acknowledges that the answers provided herein are based on a reasonable inquiry and/or investigation. The Applicant warrants that the above
statements and particulars together with any attached or appended documents are true and complete and do not misrepresent, misstate or omit any material
facts.
FRAUD WARNING
Page 6 of 7
The Applicant agrees to notify us of any material changes in the answers to the questions on this questionnaire which may arise prior to the effective date of any
policy issued pursuant to this questionnaire and the Applicant understands that any outstanding quotations may be modified or withdrawn based upon such
changes at our sole discretion. Completion of this form does not bind coverage. Applicant’s acceptance of the company’s quotation is required prior to binding
coverage and policy issuance. All written statements and materials furnished to the company in conjunction with this application are hereby incorporated by
reference into this application and made a part of this application.
Applicant: _______________________________________ Title:
FEIN #: _________________________________________
Applicants Signature: _______________________________ _____ Date:
Agent/Broker Name:
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Page 7 of 7
If reporting more than one claim or incident, please photocopy and complete a separate form for each. Attach additional
sheets if necessary for adequate explanation. All questions must be answered or marked Not Applicable (N/A), and each
sheet must be signed.
Name of Patient:____________________________________________ Age:______ Sex:_______
Incident Claim
Date reported to insurance company: ______________
Name of insurance company: _______________________________________________
Date of incident and your treatment: __________________________________________________________
Allegations / Circumstances: ___________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Additional Defendants: _______________________________________________________________________
What is the present condition of the patient?______________________________________________________
___________________________________________________________________________________________
STATUS OF CLAIM
Suit threatened, no action taken Court outcome in YOUR favor: Unresolved/Open
Suit filed but dropped by claimant Jury verdict Awaiting mediation
Summary judgment in your favor Directed verdict Awaiting court action
Reserve amount:
$__________________
Suit settled out of court Court outcome in favor of plaintiff:
a. Date claim paid: _____________ Jury verdict
b. Amount paid: $_____________ Directed verdict
c. Did you want to settle? Amount of loss payment:
Yes No $_____________________
Name and address of the attorney assigned to your case: ____________________________________________
___________________________________________________________________________________________
To your knowledge, was any settlement paid by another party involved (i.e., your P.A., P.C., partners, employees, etc.)?
Yes: No:
Explain in detail what action(s) you have taken to prevent recurrence of this type of claim:
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Signature: __________________________________ Date:_____________________
Printed Name: __________________________________
SUPPLEMENTAL CLAIM / INCIDENT INFORMATION
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RENEWAL AH HOME HEALTH And MEDICAL STAFFING Final (Kinsale Insurance)

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Completed 15 July 2020

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