Fillable SOCIAL SERVICE AND HEALTHCARE PROFESSIONAL LIABILITY APPLICATION (Risk Placement Services, Inc.)

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SOCIAL SERVICE AND HEALTHCARE PROFESSIONAL LIABILITY APPLICATION (Risk Placement Services, Inc.)

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MP 4004 06 14
Copyright, American Alternative Insurance Corporation, 2013
Page 1 of 8
SOCIAL SERVICE AND HEALTHCARE
PROFESSIONAL LIABILITY APPLICATION
THIS APPLICATION IS ON AN OCCURRENCE COVERAGE BASIS.
THIS APPLICATION IS ON A CLAIMS-MADE COVERAGE BASIS.
NOTICE: THIS APPLICATION IS FOR A COVERAGE PART WRITTEN ON A CLAIMS-MADE BASIS.
"CLAIMS" MUST BE FIRST MADE AGAINST ANY INSURED DURING THE POLICY PERIOD OR ANY
APPLICABLE EXTENDED REPORTING PERIOD, AND REPORTED TO US AS SOON AS PRACTICABLE
DURING THE POLICY PERIOD, ANY SUBSEQUENT RENEWAL OF THE POLICY OR ANY APPLICABLE
EXTENDED REPORTING PERIOD. THE INSURANCE FOR WHICH THIS APPLICATION IS MADE
APPLIES ONLY IF THE "WRONGFUL ACT" OUT OF WHICH THE "CLAIM" AROSE OCCURRED ON OR
AFTER THE RETROACTIVE DATE, IF ANY, SHOWN IN THE DECLARATIONS AND BEFORE THE END
OF THE POLICY PERIOD.
Please answer all questions completely. If there is insufficient space to complete an answer, please continue on a
separate sheet indicating the question number. This Application must be completed, signed, and dated by an
officer, director or equivalent executive of the Organization. Please include all attachments referenced throughout
the Application and complete any supplemental applications referenced within the Application. Please type or
print.
The information requested in this Application is for underwriting purposes only and does not constitute notice to
the Insurer under any Policy of a Claim or potential Claim. All such notices must be submitted to the Insurer
pursuant to the terms of the Policy, if and when issued.
All questions must be completed to enable us to provide you with a quote. Please include any brochures
or descriptive materials that may assist us in a better understanding of your agency.
I. YOUR AGENCY
1.The precise
name of y
o
ur agency including any “D/B/A’
s”
___________
For Profit Non-Profit Other; Describe _________
2.Your mailing address:
City and State Zip
Effective Date of Coverage: Webpage address: ______
Please provide the addresses of all locations owned/leased by the insured to be covered:
STREET ADDRESS CITY AND STATE ZIP CODE OCCUPANCY/EXPOSURE
(1)
(2)
(3)
MP 4004 06 14
Copyright, American Alternative Insurance Corporation, 2013
Page 2 of 8
(4)
3. Please provide a brief description of your operations.
4. How long has your agency been in operation? _ What is your annual budget? ____________________
a. Name all subsidiary companies/locations and other operations within applicant’s control.
_______
b. Has applicant sold, acquired or discontinued any operations in the last 5 years? If yes, explain.
5. Please give a complete percentage breakdown of your funding sources (total to equal 100%).
_________________________________________________________________________________________
6. Are you aware of any state, federal, local code or professional ethics violations by your agency or any of your
employees?
Yes No
7. Are you licensed by the state(s) in which you operate?
Yes No If No, is a license required?
(Please attach a copy of license and latest inspection)
If yes, is it renewed
annually semi-annually other
Has your license ever been suspended or revoked? Yes No
If yes, please give details.
8. Provide the following information:
a. Is a complete background investigation required for all staff?
Yes No
b. Do you verify employment related references?
Yes No
c. Do you verify educational requirements?
Yes No
d. Do you conduct a personal interview?
Yes No
e. Are licenses checked for employees/volunteers, when appropriate?
Yes No
f. Do you have a plan of supervision that monitors staff in day-to-day relationships with clients?
Yes No
g. Do you have a crisis management plan for dealing with staff, victim, parents, authorities and media if
you have an incident of abuse?
Yes No
h. Do you maintain training programs for your staff?
Yes No
If yes, are they mandatory? Yes No
Describe training offered ___________________________________________________
II. YOUR OPERATIONS
9. PLEASE CHECK YES or NO TO THE SERVICE (S) BELOW THAT BEST DESCRIBE YOUR
OPERATION. Check all that apply.
a. RESIDENTIAL CARE: Do you operate any Residential Facilities?
Yes No
(If "Yes", please complete a Residential Facility Questionnaire MP4004c for each facility.)
b. FOSTER CARE/ADOPTION PLACEMENT SERVICES: Yes No
(If "Yes", please complete attached Foster/Adoption Placement Supplement MP4004b.)
c. OUTPATIENT SERVICES:
YES NO # Clients(annual) #of Days No.
Drug & Alcohol Treatment: Individual
`
MP 4004 06 14
Copyright, American Alternative Insurance Corporation, 2013
Page 3 of 8
Drug & Alcohol Classes (DUI/DWI)
Mental Health Counseling: Individual
Mental Health Counseling: Group
MR Treatment Center
Cerebral Palsy Center
Rehabilitation Agency
Case Management (MH/MR/Comm. Support)
Training
Hospice (outpatient)
Family Skills Training
Referral Agency
Day Schools
Home Studies
CASA(Court Appointed Special Advocates)
Advocacy Services
Independent Living Skills Training
Before & After School Care ______ ______
Headstart Program ______ ______
Day Camps for Mentally Ill
or Developmentally Disabled ______ ______
Day Care for Mentally Ill or Dev. Dis.
Sheltered Workshop/Work Activity ______ ______
Recreation Program
*Agencies for Aging/Senior Citizens
d.
Home Care ______ Home Health Care _____Respite Care _______Loc #
Age Range of Clients (please enter the number of clients in each age group):
Level of Care: Developmentally Disabled 0-17 ______ 18-60 60+
Mentally Impaired 0-17 ______ 18-60 60+
Other 0-17 ______ 18-60 60+
Please describe services provided
e. Methadone Maintenance Clinic No. of Licensed Slots: Loc No.
f. Meals on Wheels No. of Meals Annually: Loc No.
g. Hotline Center No. of Calls Annually: Loc No.
h. Mentorship No. of Matches: _________How often do they meet?__________
i. Other Services not described above; Include # of Client Contacts/Appointments annually
_____ Loc No.
10. STAFF Employees Non-Employees (Volunteers/Consultants)
No. Full time No. Part Time No. Full time No. Part Time
RN'S/LPN'S
CNA/Caregivers
Physicians Assts. _____________ _____________ _____________ _____________
Nurse Practitioners _____________ _____________ _____________ _____________
Social Workers
Residence Managers
Counselors
Physicians
Psychologist
Psychiatrist
MP 4004 06 14
Copyright, American Alternative Insurance Corporation, 2013
Page 4 of 8
Occupational Therapist
Physical Therapist
Personal Trainer
Health /Fitness Instructor
Nutritionist/Dietician
Others (specify)
(Include any Medical Director(s) in appropriate class)
11. Total Number of Staff:_____________ Ratio of Staff to Clients:________(staff) to ________(clients)
Annual Staff turnover rate:___________%
12. Does your staff include any of the following types of professionals?
Accountant
Yes No If yes, how many?_____________
Attorney
Yes No If yes, how many?_____________
Architect
Yes No If yes, how many?_____________
Engineer
Yes No If yes, how many?_____________
Financial Advisor/Consultant
Yes No If yes, how many?_____________
If you would like coverage for these individuals please complete the appropriate Supplemental
Miscellaneous Professional Application.
13. Do you handle clients’ money, bills or finances of any type?
If yes, please give details(what is handled and what controls are in place).
________________________________________
14. Are any of your facilities in operation 24 hours? Yes No. If yes, is there a supervisor on duty 24
hours?
Yes No
III. MEDICAL STAFF & PROCEDURES
15. Do you have any employed, volunteer or contracted Physicians/Psychiatrists serving your organization?
Yes No Do you want coverage for these Physicians and Psychiatrists? Yes No
(If Yes, complete the Licensed Practitioner of the Healing Arts Supplemental Application for each
professional.,MP4004a)
16. Do you provide any primary medical or skilled nursing services? Yes No If yes, please explain.
17. Do you or any of your staff prescribe or administer any medications? Yes No If yes, please provide a
list on a separate sheet of paper of the medications, who prescribes them, for what purpose, and how they are
secured.
18. Do you have Policies & Procedures in place for prescribing/administering medication?
Yes No
Are non-FDA approved drugs prescribed or administered?
Yes No
19. Are you involved in any of the following; Clinical Trials, pharmaceutical testing or research
Yes No
If yes, please describe:
20. Does a physician screen client prior to admission? Yes No If no, please describe procedure which
determines who is eligible for admission:
_____________________________________________________________________________________
21. Are Patients physically restrained? Yes No
22. Do you have facilities for surgery, x-rays, or other medical treatment?
Yes No
If yes, please describe:
23. Do you contract with any other facilities for additional beds? Yes No If yes, please indicate the
number or estimated number of beds and provide a copy of the contract. No. of Contracted beds_______
24. Does your agency recommend release, parole or incarceration of clients?
Yes No
MP 4004 06 14
Copyright, American Alternative Insurance Corporation, 2013
Page 5 of 8
(If yes, please explain on a separate sheet of paper.)
25. Do you treat any sexual offenders?
Yes No
(If yes, please explain on a separate sheet of paper.)
26. Do you service clients recently released from a lock-up facility?
Yes No
(Describe the nature of offenses on a separate sheet of paper.)
IV. ADDITIONAL INSUREDS (PROFESSIONAL LIABILITY)
Insurable Interest - Check box that applies
Name:
Funding/Grant Contract/Services Other
Address: Describe:
Name: Funding/Grant Contract/Services Other
Address: Describe:
Name: Funding/Grant Contract/Services Other
Address: Describe:
V. YOUR INSURANCE HISTORY
LINE
COMPANY
LIMITS
PREMIUM
DED
EFFECTIVE/
EXPIRATION
DATE
RETROACTIVE
DATE
Professional
Liability
27. If you have not purchased coverage before, please explain.
28. Is your expiring professional liability coverage on a claims made basis? Yes No
If yes, would you like us to include prior acts coverage?
Yes No
If yes, please provide proof of uninterrupted claims made coverage since the retroactive date requested.
29. Has any carrier cancelled or refused coverage for your agency?
Yes No
(THIS QUESTION DOES NOT APPLY TO APPLICANTS IN MISSOURI)
If yes, please explain.
VI. CLAIM INFORMATION
30. Have you had any claims and/or circumstances that have not been previously reported? Yes No
If yes, please attach detailed claim information with the date of the loss or occurrence, the status, the amount
reserved or paid and a description of the claim or allegation.
Please attach 5 years loss history for your professional liability coverage.
31. Please describe your procedures when reporting potential incidents to the proper authorities.
______
NOTICE TO APPLICANT – PLEASE READ CAREFULLY
FOR THE PURPOSE OF THIS APPLICATION, THE UNDERSIGNED, AS AUTHORIZED AGENT FOR ALL
PERSONS AND ENTITIES PROPOSED FOR THIS INSURANCE, DECLARES THAT TO THE BEST OF
HIS/HER KNOWLEDGE THE STATEMENTS HEREIN ARE TRUE AND COMPLETE. THE INSURER IS
AUTHORIZED TO MAKE ANY INQUIRY IN CONNECTION WITH THIS APPLICATION. SIGNING THIS
A
PPLICATION DOES NOT BIND THE INSURER TO ISSUE, OR THE APPLICANT TO PURCHASE, ANY
MP 4004 06 14
Copyright, American Alternative Insurance Corporation, 2013
Page 6 of 8
INSUR
A
NCE POLICY.
THE INFORMATION CONTAINED IN AND SUBMITTED WITH THIS APPLICATION IS ON FILE WITH THE
INSURER. IF THE INFORMATION IN THIS APPLICATION MATERIALLY CHANGES PRIOR TO THE
EFFECTIVE DATE OF THE COVERAGE PART, THE APPLICANT MUST NOTIFY THE INSURER, WHO MAY
MODIFY OR WITHDRAW THE QUOTATION.
THE UNDERSIGNED, AS THE AUTHORIZED REPRESENTATIVE OF THE INSURED ACKNOWLEDGES
THAT THEY HAVE BEEN ADVISED THAT:
A. IF THE CLAIMS-MADE COVERAGE BASIS BOX IS SELECTED, THIS POLICY APPLIES ONLY TO
"CLAIMS" FIRST MADE OR DEEMED MADE AGAINST THE INSUREDS DURING THE POLICY
PERIOD OR EXTENDED REPORTING PERIOD, IF EXERCISED.
(WORDS WITHIN QUOTATION MARKS ARE DEFINED IN THE INSURANCE COVERAGE FORM.)
FRAUD STATEMENT
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.
FRAUD STATEMENT TO ALABAMA APPLICANTS
Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who
knowingly presents false information in an application for insurance is guilty of a crime and may be subject to
restitution fines or confinement in prison, or any combination thereof.
FRAUD STATEMENT TO ARKANSAS 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.
FRAUD STATEMENT 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 policyholder or
claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to
settlement or award payable from insurance proceeds shall be reported to the Colorado division of insurance
within the department of regulatory agencies.
FRAUD STATEMENT 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.
FRAUD STATEMENT TO FLORIDA APPLICANTS
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 of the third
degree.
FRAUD STATEMENT 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.
FRAUD STATEMENT 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.
MP 4004 06 14
Copyright, American Alternative Insurance Corporation, 2013
Page 7 of 8
FRAUD STATEMENT 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 a denial of insurance benefits.
FRAUD STATEMENT TO MARYLAND APPLICANTS
Any person who knowingly and willfully presents a false or fraudulent claim for payment of a loss or benefit or
who knowingly and willfully presents false information in an application for insurance is guilty of a crime and
may be subject to fines and confinement in prison.
FRAUD STATEMENT 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.
FRAUD STATEMENT 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.
FRAUD STATEMENT TO NEW YORK APPLICANTS
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 also be subject to a civil penalty not to exceed five thousand dollars and the stated
value of the claim for each such violation.
FRAUD STATEMENT TO OHIO APPLICANTS
Any person who, with intent to defraud or knowing that he 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.
FRAUD STATEMENT 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.
FRAUD STATEMENT TO OREGON APPLICANTS
Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly
presents materially false information in an application for insurance may be guilty of a crime and may be subject
to fines and confinement in prison.
FRAUD STATEMENT 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 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.
FRAUD STATEMENT TO RHODE ISLAND 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, including failing to disclose whether the applicant or
applicants have been convicted of any degree of the crime of arson, is guilty of a crime and may be subject to fines
and confinement in prison.
FRAUD STATEMENT 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.
FRAUD STATEMENT TO VERMONT APPLICANTS
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 may be a crime and subjects such person to criminal and civil penalties.
MP 4004 06 14
Copyright, American Alternative Insurance Corporation, 2013
Page 8 of 8
FRAUD STATEMENT 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.
FRAUD STATEMENT TO WASHINGTON 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.
FRAUD STATEMENT TO WEST VIRGINIA 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.
______________________________________________ _______/_______/_______
Signature of Applicant Date
______________________________________________
Name and Title
This application form duly completed, together with any supplementary information must be signed in ink by the
applicant
__________________________ ___________________________________
Please Print Name Signature of Producer submitting Date Signed
Producing Agency :
Address:
Telephone: ( )
Did you remember to?
If you have Physicians on staff and are requesting Physicians coverage :
Complete the Licensed Practitioner of the Healing Arts Supplemental Application for each professional.
to be named on the policy
If you are a Foster Care or Adoption Agency :
Complete the Foster Care and Adoption Care Supplement
If you have a Residential/Respite/Daycare Facility:
Complete the Residential Facility Supplement
If you have a Vocational or Sheltered Workshop :
Complete the Vocational/Sheltered workshop Supplement
If you have specific Professionals on staff and are requesting Miscellaneous Professional coverage:
Complete the appropriate Miscellaneous Professional Liability application for the professionals
identified in Question 15 of this application.
If you are applying for Sexual Abuse or Molestation coverage:
Complete the appropriate Sexual Abuse Or Molestation Liability application .
General Reminders:
Did you complete each question in all applicable sections as we cannot offer a quote based on
incomplete information?
Did you sign and date all applications?
Did you attach current loss runs?
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SOCIAL SERVICE AND HEALTHCARE PROFESSIONAL LIABILITY APPLICATION (Risk Placement Services, Inc.)

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Completed 23 November 2020

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