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SUBSTANCE ABUSE REHABILITATION FACILITY (Philadelphia Insurance Companies)

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SUBSTANCE ABUSE REHABILITATION FACILITY
Pages 1 – 7 and the Fraud Statement must be completed by all Applicants
REQUIREMENTS FOR SUBMISSION
• Completed ACORD Application(s) • Currently valued insurance company loss runs for the
current policy period plus three (3) prior years
• Statement of Values
• Brochures and / or website information • Copy of all current licenses
SECTION I – GENERAL APPLICANT INFORMATION
1. Applicant’s annual operating budget: $ Applicant’s annual payroll: $
2. Total number of clients: Total number of methadone-only clients:
3. Have there been any mergers or operations under another name within the past 5 years? Yes No
4. Are any mergers or changes in operation anticipated? Yes No
If Applicant answered yes to either question #3 or #4 above, please explain on a separate sheet.
5. Has the Applicant’s license ever been suspended, revoked, or placed under conditional status? Yes No
6. 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, please send a copy of the most current federal, state or agency complaint investigation
report.
7. Has the Applicant discontinued any programs in the past five years? Yes No
If yes, please explain:
8. Facility director information:
Name: Education level:
Number of years’ experience: Number of years at this facility:
9. Is treatment individual or group?
SECTION II – AGENCY SERVICES AND PROGRAMS
1.
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
Applicant’s name:
Website address:
Under 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:
Accreditations: Joint Commission CARF ACHC Other:
Are facilities licensed by a regulatory authority?
If Yes, please attach current copy of license for each facility.
Yes No
Risk Management Contact: Risk Management’s Phone:
Risk Management Email:
Substance Abuse Rehabilitation Facility
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2.
Does the Applicant provide integrated behavioral health and primary medical care services?
No
If yes, please describe the Applicant’s program model:
SECTION III – RISK ASSESSMENT
1. Has the Applicant implemented an evidence-based program? Yes No
If yes, please provide the name of the program(s) you have implemented:
a.
b.
2. Please provide the following percentages for the clients served:
Client Percentage
Male
%
Female
%
Previously participated in detox programs
%
Violent Offenders
%
3. Does the Applicant’s organization have formal risk management guidelines for Applicant’s
practitioners to follow?
Yes No
4. Are the guidelines reviewed every two years? Yes No
5. Does the Applicant’s staff receive job descriptions? Yes No
6. Is formal training provided to staff? Yes No
7. What is the Applicant’s de-escalation/physical restraint policy?
3. Does the Applicant’s program include involuntary treatment (other than alcohol-related traffic
offenders)? Yes No
If yes, what % of the Applicant’s overall operation? % Voluntary % Involuntary
4. Yes No Does the Applicant’s program include providing services for Correctional Facilities?
If yes, what percent of your overall operation? %
5. Yes No Does the Applicant provide or utilize telemedicine or telehealth services?
If yes, please provide the following:
a. Complete description of the services:
b. Include the names and qualifications of all health professionals involved
i.
ii.
6. Methadone Treatment – is there a methadone treatment program? Yes No
a. Is the program maintenance only? Yes No
b. Is there a methadone detox program? Yes No
c. Where is the methadone stored?
d. Number of methadone-only clients:
d. Number of clients with take home privileges:
e. Yes No Does the facility maintain a Diversion Control plan?
If yes, please describe measures the Applicant employs to guard against the diversion of
methadone by employees and/or clients:
7. If detoxification unit is operated, is it Social or Medical?
If Medical detox is operated please provide copies of all intake and discharge procedures related to medical detox.
8. If “Medical”, does the Applicant accept clients with a history of delirium tremens (DTs) or seizures? Yes No
9. If clients are experiencing DTs or seizures, does the Applicant treat them, or refer them to a
hospital? Yes No
10. Does the Applicant perform any “rapid detox” or any detox under general anesthesia? Yes No
11. 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:
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8.
Is more than one person responsible for the welfare of any single patient?
No
9.
During intake, are screening practices written and clearly communicated to all practitioners to
quickly identify how well the individual matches the organization’s services?
No
10.
Are written instructions and training provided to the Applicant’s staff that:
a.
Identify urgent need?
No
b.
Ensure a prompt response to emergency situations?
No
c.
Provide timely initiation of services?
No
d.
Provide measurement and feedback to management?
No
11.
Do the Applicant’s intake procedures include a risk assessment that identifies specific
characteristics of the individual served for potential suicide?
No
12.
Do the Applicant’s intake procedures include physical examination and complete bio-psycho-
social documentation?
No
13.
No
No
Do the Applicant’s intake procedures include blood tests?
If yes, are the blood tests used for any purpose outside of drug testing?
If yes, please describe any other uses and possible disclosures from blood tests:
14.
Have any of the Applicant’s clients attempted or committed suicide?
No
If yes, please indicate:
Year
# of Clients
Year
# of Clients
15.
Does the Applicant use a no suicide contract?
No
16.
Does the Applicant administer medications?
No
If yes, please complete the following questions:
a.
At the time the individual enters the Applicant’s organization, is a complete list of medications
he or she is taking created and documented?
No
b.
At the time the individual is transferred within or outside the Applicant’s organization, does the
current provider inform and document the receiving provider about the medication list?
No
c.
At the time an individual leaves the Applicant’s organization, is a current list of medications
provided and explained to the individual, family and the individual’s primary care provider?
No
17.
Does the Applicant’s risk management program include instructions for medical record
documentation?
No
If yes, is there a quality improvement program in place to monitor the documentation?
No
18.
Does the Applicant maintain all medications in a locked area?
No
19.
Does the Applicant have incident reporting procedures and/or committee reviews?
No
20.
Are written agreements in place with independent contractors?
No
21.
Are certificates of liability insurance obtained and maintained for all contracted service providers
/independent contractors?
No
If yes, please indicate the limit of liability required: $
22.
Does the Applicant operate a medical clinic?
No
If yes, is it open to the public?
No
23.
Does the Applicant sponsor any fund raising activities?
No
If yes, on a separate sheet please provide a list with a description of each.
SECTION IV – PROFESSIONAL LIABILITY
1.
Does the Applicant’s current insurance program include coverage for Professional Liability?
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?
No
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4.
Annual Staffing – Employees, Independent Contractors and Volunteers
Total number of:
Full time employees:
Part Time Employees:
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
Staffing
# of Employees # of Contracted
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.
Volunteers:
Total Annual Volunteer
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SECTION V – HIRING AND SCREENING
1.
Check methods used for all employees, independent contractors or volunteers:
Criminal Background Checks:
Federal
State
Validate Driver’s License
Drug Testing
Validate Education
MVR
Validate Personal Auto Insurance and Limits
Personal Interview
Validate Work History
Reference Checks
Verification of current certification/professional license
Sexual Abuse Registry
Other:
2.
How are references checked?
Written
Verbal
Both
3.
Are all methods completed before an offer of employment is made?
Yes
No
4,
Does the Applicant have a formal volunteer program?
Yes
No
5.
Does the Applicant verify if potential employees and individual contractors have ever had their
license revoked or suspended, or disciplinary action taken against them?
Yes
No
6.
What is the staff turnover rate for the last 12 months?
7.
Are any staff members or volunteers under 21 years of age?
Yes
No
SECTION VI – BUILDING INFORMATION
N/A
(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.
Sprinklers?
Yes
No
If yes, area 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.
Are swimming pools located on the premises?
Yes
No
If yes, are all swimming pools & spas compliant with Virginia Graeme Baker Pool & Spa Safety
Act?
Yes
No
6.
Emergency lighting?
Yes
No
7.
Fire alarms?
Yes
No
8.
Smoke Detectors?
Yes
No
If yes:
Battery operated Hard-wired
9.
Carbon Monoxide Detectors?
Yes
No
10.
Are evacuation routes posted throughout the building?
Yes
No
11.
In the event of an evacuation, has a central meeting point outside the building been established?
Yes
No
12.
Are exit signs illuminated?
Yes
No
13.
Are fire drills held?
Yes
No
14.
Are there at least two exit doors per building?
Yes
No
15.
Are exit doors equipped with panic hardware?
Yes
No
16.
Are handrails on all ramps and steps?
Yes
No
17.
Is smoking permitted inside the building?
Yes
No
18.
Have all buildings built before 1971 been inspected for lead paint?
Yes
No
19.
Type of security provided:
Guards
Video Camera
Other:
SECTION VII – RESIDENTIAL FACILITY
N/A
(Please complete for each residential facility)
Facility address:
Licensed capacity - number of beds:
# of stories:
Year built:
1.
Referral Source:
Community agencies
Extended care facility
Physicians office
Court ordered
Hospital
Suicide Intervention
Detox Program
Hotline
Other:
2.
Are residents screened by a physician prior to admission?
Yes
No
If no, on a separate sheet please describe the procedure that determines who is eligible for admission.
3.
Resident age groups:
Under 18: %
18 – 65: %
Over 65: %
Male: %
Female: %
Co-ed: %
How are residents separated?
4.
Number of beds:
Average occupancy:
Average length of stay:
5.
Number of non-ambulatory clients:
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6.
Are resident’s rooms located on the ground floor?
Yes
No
7.
Are formal sign-in and sign-out procedures in place?
Yes
No
8.
Does the Applicant control entrance and exit of residents?
Yes
No
9.
Does the Applicant control entrance and exit of visitors?
Yes
No
10.
Does the Applicant allow guests/visitors to stay overnight?
Yes
No
11.
Does the Applicant have 24-hour supervision?
Yes
No
If so, please describe:
12.
Are there locks on doors to sleeping areas?
13.
On a separate sheet, please describe discharge policy
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.
What percentage of residents requires medication to maintain stable mental condition? %
16.
Has the Applicant developed written procedures for a standardized “handoff” process to ensure
accurate communication of essential elements of care between shift changes?
Yes
No
17.
Bed check procedures:
a.
Time intervals:
b.
Qualifications of staff performing:
c.
Documentation procedures:
d.
Video surveillance:
Yes
No
18.
Water heater temperature setting:
Are anti-scald devices installed?
Yes
No
SECTION VIII – RECREATIONAL ACTIVITIES
N/A
1.
Is a waiver required to be signed by the participant, or the parent or guardian of the participant prior
to participation in all athletic activities?
Yes
No
If yes, has your waiver been reviewed by legal counsel? Please attach copy of waiver.
2.
Please indicate all of the recreation activities offered by the Applicant’s program.
Aerobics and other aerobic activities
Horse Back Riding
Archery
Kayaking
Baseball/softball/basketball/soccer
Motorized vehicles (ATVs, etc.)
Bicycling
Obstacle Course(s)
Football -- Flag / Tackle
Paintball
Other:
Other:
Rock Climbing / Rappelling
Scuba
Shooting Ranges
Skiing
Snorkeling
Other:
3.
Please describe each of the activities indicated above the safety controls in place:
SECTION IX – ABUSE AND MOLESTATION
1. Does the Applicant’s employment process include verification of whether the individual has ever
been convicted of any crime, including sex-related or child abuse related offense, before an offer of
employment is made?
Yes No
2. Are background checks performed on Independent Contractors who have access to children and
clients or who perform operations where they will be physically touching another person?
Yes No
3. Does the Applicant have a plan of supervision that monitors staff in day-to-day relationships with
clients both on and off premises?
Yes No
4. Has the Applicant’s organization ever had an incident which resulted in an allegation of sexual
abuse?
Yes No
a. Was a claim made against the organization? Yes No
b. Was a claim made against any employee? Yes No
If yes, is that individual still employed with the Applicant’s organization? Yes No
c. Was the case settled? Yes No
d. What changes were made to prevent reoccurrence? Yes No
On a separate sheet, please describe all claims.
Yes No
Yes No
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5.
Does the Applicant have written abuse and molestation procedures and are they clearly
communicated to all employees, independent contractors and volunteers?
Yes
No
6.
Does the Applicant’s current insurance program include coverage for Abuse and Molestation?
Yes
No
If yes, please provide carrier information.
7.
Prior carrier:
Company
Limits of
Liability
Effective
Dates
Annual
Premium
Claims Made
or Occurrence
Retroactive Date
(Claims Made Only)
SECTION X - AUTOMOBILE
1.
What percentage of employees/volunteers use their own vehicles regularly for agency business?
Employees: %
Volunteers: %
2.
Does the Applicant have a driver safety training program?
Yes
No
3. Would the Applicant be willing to participate in Online Driver Training provided by PHLY? Yes No
4. Does the Applicant have a vehicle maintenance program? Yes No
5. Does the Applicant transport clients? Yes No
6. Does the Applicant allow clients or peers to operate the Applicant’s motor vehicles? Yes No
7. Is training provided for new employees prior to their transporting clients? Yes No
8. If transporting more than five clients, are two employees required to be present? Yes No
9. Yes No Does the Applicant transport clients/consumers for other private or government agencies?
If yes, please explain:
If yes, for a fee? Yes No
10.
Yes No
Does the Applicant require employees and volunteers to carry and show evidence of personal
insurance?
If yes, what limits are required? $
11. Yes No Does the Applicant’s organization utilize GPS fleet telematics devices?
If yes, please check off the fleet telematics being utilized:
Plug in Hard wired Mobile Phone Other:
12. What percentage of the Applicant’s fleet is provided with these fleet telematics devices? %
13. Estimated annual mileage of transportation provided:
Estimated annual transportation trips:
14. Percentage of transportation is provided by?
Owned autos: % Non-owned autos: % Hired Autos: %
SECTION XI – CLAIMS MADE
Notice: This section is being completed as an application for a Claims-Made policy. Only claims which are first
made against the Applicant and reported to us during the policy period or Extended Reporting Period will be
covered, subject to policy provisions. Various provisions in the policy restrict coverage. Read the entire policy
carefully to determine the Applicant’s rights, duties and what is and is not covered.
N/A (Please proceed to signature section)
Policy Effective Date:
Line of Business:
1.
Yes No
Within the past 5 (five) years has the Applicant given written notice under the provisions of any
current or prior policy providing similar insurance of any claim or of any specific facts or
circumstances which might give rise to a claim being made against the Applicant?
If yes, please provide details:
2.
Yes No
With respect to the coverages applied for, upon inquiry of any of person qualifying as a Named
Insured under the proposed policy, are there any facts, circumstances, or situations which might
give rise to a claim under the coverage(s) for which the Applicant is applying?
If yes, please provide details:
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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 trace,
full insulation on piping or roof):
6.
General Comments:
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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, 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 COMPLETE
D 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 Rehabilitation Facility
Page 9 of 9
© 2018 Philadelphia Consolidated Holding Corp.
08/2018
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SUBSTANCE ABUSE REHABILITATION FACILITY (Philadelphia Insurance Companies)

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Completed 29 July 2020

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