Fillable RENEWAL AH Medical Transportation 1 (Kinsale Insurance)

Fill Online, Printable, Fillable, Blank RENEWAL AH Medical Transportation 1 (Kinsale Insurance) Form

Use Fill to complete blank online KINSALE INSURANCE pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

RENEWAL AH Medical Transportation 1 (Kinsale Insurance)

On average this form takes 44 minutes to complete

The RENEWAL AH Medical Transportation 1 (Kinsale Insurance) form is 6 pages long and contains:

  • 2 signatures
  • 41 check-boxes
  • 150 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your Kinsale Insurance forms online.

BROWSE KINSALE INSURANCE FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Page 1 of 6
RENEWAL APPLICATION - AMBULANCE AND NON-EMERGENCY TRANSPORT
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 indicate the services and operations that best describes your organization
(check all that apply)
Number of Vehicles
Van / Sedan Transportation
______Vans ______Sedans
Wheel Chair Transportation
______ Wheelchair
Non-Emergency Medical Transportation (Ambulance)
______ Total Number of Ambulances
Emergency Transportation (Ambulance)
Air Ambulance Transport (Helicopter or Fixed Wing)
______ Fixed Wing _____ Helicopter
BUS Transport (or any vehicle with a passenger capacity greater than 15)
______ BUS
GENERAL INFORMATION
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
OPERATIONS
Kinsale Insurance Company
P. O. Box 17008
Richmond, VA 23226
(804) 289-1300
www.kinsaleins.com
Page 2 of 6
8. Please state source and amounts of total revenue and client transports:
REVENUES / SALES
Source:
Ambulette/ Wheelchair / Sedans
Non-Emergency (BLS)
Non-Emergency (ALS)
Emergency Transports
Air Ambulances
Other – specify _________________
TOTAL GROSS REVENUES
LAST 12 months
$________________
$________________
$________________
$________________
$________________
$________________
$ _______________
NEXT 12 months
$________________
$________________
$________________
$________________
$________________
$________________
$________________
CLIENT TRANSPORTS
Ambulette/ Wheelchair / Sedans
Non-Emergency (BLS)
Non-Emergency (ALS)
Emergency Transports
Air Ambulances
Other – specify _______________
Total Calls
LAST 12 months
________________
________________
________________
________________
________________
________________
________________
NEXT 12 months
________________
________________
________________
________________
________________
________________
________________
9.
Name of your Auto Liability Insurance Carrier for the upcoming policy year?
Name of Carrier
Limit of Liability
Effective Dates of Coverage
$_____________________
___ / ___ / _____ to ___ / ___ / _____
10.
Does your Auto Liability policy specifically
exclude
claims arising from loading and unloading patients?
YES NO
11. Does your Auto Liability policy specifically include claims arising from loading and unloading patients?
YES NO
12. Does your Auto Liability policy remain silent on the applicability of coverage for claims arising from
loading or unloading of patients?
YES NO
13. Have there been any other major changes in exposures (acquisitions, new, or discontinued services)
which are not reflected above? If yes, please provide details.
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
YES NO
Page 3 of 6
14.
Please provide number of:
Employees
Independent Contractors
Volunteers
Full-Time
Part-Time
Full-Time
Part-Time
Full-Time
Part-Time
Drivers
EMT Basic
EMT Intermediate
EMT Paramedic
Physicians
RN’s
Other (describe)
CLAIMS HISTORY - Provide details for all “yes” answers to questions 13-18
STAFF
15. 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 on page 4 or attach additional
pages as needed.
YES NO
16.
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 page 4 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 diagnosed or treated for
alcoholism, drug addiction, any chemical dependency, or mental or chronic physical illness? Explain on
page 4 or attach additional pages as needed.
YES NO
18.
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
19. 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
20.
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
Page 4 of 6
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.
SUPPLEMENTAL INFORMATION
Use this page as needed or to address questions referenced within the application.
FRAUD WARNING
Page 5 of 6
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.
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 #:
_____________________________________
Applicant’s Signature:
___________________________
Date:
_______________________________
Agent / Broker Name:
_____________________________________________________________________
click to sign
signature
click to edit
Page 6 of 6
If reporting more than one claim, then please photocopy this form 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:_______
Date reported to insurance company:
_____ / _____ / ________
Name of insurance company:_____________________________________________________
Date of incident and your treatment:_______________________________________________
Allegations:____________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Additional Defendents:___________________________________________________________
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 CLAIMS INFORMATION
click to sign
signature
click to edit
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

RENEWAL AH Medical Transportation 1 (Kinsale Insurance)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 16 July 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document