Fillable SUBSTANCE ABUSE FACILITY RENEWAL APPLICATION (Philadelphia Insurance Companies)

Fill Online, Printable, Fillable, Blank SUBSTANCE ABUSE FACILITY RENEWAL APPLICATION (Philadelphia Insurance Companies) Form

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

SUBSTANCE ABUSE FACILITY RENEWAL APPLICATION (Philadelphia Insurance Companies)

On average this form takes 86 minutes to complete

The SUBSTANCE ABUSE FACILITY RENEWAL APPLICATION (Philadelphia Insurance Companies) form is 5 pages long and contains:

  • 0 signatures
  • 8 check-boxes
  • 339 other fields

Country of origin: US
File type: PDF

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

BROWSE PHILADELPHIA INSURANCE COMPANIES 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
 
SUBSTANCE ABUSE FACILITY – RENEWAL APPLICATION
Applicant’s name:
Website address:
Non Profit
For Profit
Number of years:
In operation:
Under present management:
Is the Applicant’s organization more than 25% owned by a private equity fund structure?
Yes
If yes, provide name of private equity firm:
Accreditations:
Joint Commission
CARF
ACHC
Other:
Risk Management Contact:
Risk Management’s Phone:
Risk Management Email:
1. Applicant’s annual operating budget: $ Applicant’s annual payroll: $
2. Total number of clients: Total number of methadone-only clients:
Client Percentage
Male %
Female %
Previously participated in detox programs %
Violent Offenders %
3. Have there been any mergers or operations under another name within the past year? Yes No
4. Are any mergers or changes in operation anticipated in the coming year? Yes No
If Applicant answered yes to either question #3 or #4 above, please explain below:
5. Has the Applicant discontinued any programs in the past year? Yes No
If yes, please explain:
6. Facility director information:
Name: Education level:
Number of years’ experience: Number of years at this facility:
7.
ASAM Criteria Levels of Care
Level Service Provided % Level Service Provided %
0.50 Early Intervention % 3.30 Clinically Managed Population Specific High
Intensity Residential Services
%
1.00 Outpatient Services % 3.50 Clinically Managed High Intensity Residential %
2.10 Intensive Outpatient % 3.70 Medically Monitored Intensive Inpatient %
2.50 Partial Hospitalization % 4.00 Medically Managed Intensive Inpatient %
3.10 Clinically Managed Low
Intensity Residential
% OTS Opioid Treatment Services %
8. Does the Applicant provide integrated behavioral health and primary medical care services? Yes No
If yes, please describe the program:
9. If Methadone Treatment program is provided: Yes No
a. Is your program maintenance only, or do you offer methadone detox?
b. Where is the methadone stored?
c. Number of clients with take home privileges:
d. Describe measures to guard against the diversion of the methadone by employees and/or
clients:
Substance Abuse Facility
Renewal Application
Page 1 of 5
© 2018 Philadelphia Consolidated Holding Corp.
10/2018
Clear Application
Print Application
10.
Is there is a Detox unit?
Yes
No
a.
If yes:
Social or
Medical
b.
What is the number of staff involved in the first 72 hours of medical detoxification?
# of Physicians:
# of Nurses RN:
# of Nurses L.P.N.:
# of Nurse Practitioners:
11.
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.
Substance Abuse Facility
Renewal Application
Page 2 of 5
© 2018 Philadelphia Consolidated Holding Corp.
10/2018
Clear Application
Print Application
12.
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.
Name
Specialty
13.
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.
14.
What is the staff to client ratio for each program?
Program Staff Clients
Staff-to-Client Ratio required by Regulatory
Authority (If Applicable)
15.
Does the Applicant’s organization utilize GPS fleet telematics devices?
Yes
No
a.
If yes, please check off the fleet telematics being utilized:
Plug in
Hard wired
Mobile Phone
Other:
b.
What percentage of the Applicant’s fleet is provided with these fleet telematics devices?
%
16. Please provide an updated drivers list. (NOTE: All drivers must have acceptable MVR’s)
17. Does the Applicant allow client or peer drivers operate insured vehicles? Yes No
18. Estimated annual mileage of transportation provided:
Estimated annual transportation trips:
19. Percentage of transportation is provided by:
Owned Autos: % Non-owned autos: % Hired Autos: %
20.
.
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
Substance Abuse Facility
Renewal Application
Page 3 of 5
© 2018 Philadelphia Consolidated Holding Corp.
10/2018
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 revi
ew?
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 trace, full insulation on piping or roof):
6.
General Comments:
Substance Abuse Facility
Renewal Application
Page 4 of 5
© 2018 Philadelphia Consolidated Holding Corp.
10/2018
Print Application
Clear Application
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, VT, 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 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.
NAME (PLEASE PRINT/TYPE) TITLE
(MUST BE SIGNED BY THE PRESIDENT, CHAIRMAN, CEO OR EXECUTIVE
DIRECTOR)
_____________________________________________________________
SIGNATURE DATE
SECTION 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)
Substance Abuse Facility
Renewal Application
Page 5 of 5
© 2018 Philadelphia Consolidated Holding Corp.
10/2018
Clear Application
Print Application
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

SUBSTANCE ABUSE FACILITY RENEWAL APPLICATION (Philadelphia Insurance Companies)

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 29 July 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document