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SUBSTANCE ABUSE REHABILITATION FACILITY SUPPLEMENT TO THE MENTAL (Philadelphia Insurance Companies)

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SUBSTANCE ABUSE REHABILITATION FACILITY
SUPPLEMENT TO THE MENTAL HEALTH APPLICATION
ATTACH THIS SUPPLEMENT WHEN REQUESTED ON THE MENTAL HEALTH APPLICATION.
Name Insured:
A. AGENCY SERVICES OR PROGRAMS Scope of Operation
1) Substance Abuse Facilities
SUBSTANCE ABUSE REHABILITATION FACILITY
2) Social Detoxification
3) Medical Detoxification – First 72 Hours
4) Medical Detoxification – After 72 Hours
5) Methadone Treatment
B. PROFESSIONAL LIABILITY
1) How long has this program been in operation?
2) Percent of clients who are voluntary? %
3) Is treatment individual or group?
4) Do you provide a methadone maintenance program? Yes No
If “yes” where is the methadone stored?
Number of methadone-only clients annually:
Number of clients with take home privileges:
Describe measures to guard against the diversion of the methadone by employees and/or
clients:
5) Do you operate a detoxification unit? Yes No
If “Yes”, Social or Medical?
If “Medical”, do you accept clients with a history of delirium tremens (DTs)
or seizures?
Yes No
If clients are experiencing DTs or seizures, do you treat them or refer them to a
hospital?
What is the number of staff involved in the first 72 hours of medical detoxification?
Physicia
ns Nurses R.N. Nurses L.P.N. Nurse Practioners
6) Are facilities single sex? Yes No
7) Please provid
e allocation of clients:
Male % Female %
Under 18 years old % 19 to 50 years old
% Over 51 years old %
8) Provide percentage of clients that have partici
pated in detox programs previously? %
9) What percent of clients are ex-offenders? %
What percent of the clients are violent offenders?
%
10) What is the average length of stay for your residential facilities?
Substance Abuse Rehabilitation
Supplemental
Page 1 of 2
© 2015 Philadelphia Consolidated Holding Corp.
01/2015
Clear Application
Print Application
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, 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: 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 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 COMMITS A FRAUDULENT INSURANCE ACT.
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.
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
.
NAME (PLEASE PRINT/TYPE) TITLE
(MUST BE SIGNED BY THE PRESIDENT, CHAIRMAN, CEO OR
EXECUTIVE DIRECTOR)
____________________________________________________
SIGNATURE DATE
Produced By: (Section to be completed by Producer/Broker)
PRODUCER AGENCY
PRODUCER LICENSE NUMBER AGENCY TAXPAYER ID OR SS NUMBER
ADDRESS (STREET, CITY, STATE, ZIP)
Substance Abuse Rehabilitation
Supplemental
Page 2 of 2
© 2015 Philadelphia Consolidated Holding Corp.
01/2015
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SUBSTANCE ABUSE REHABILITATION FACILITY SUPPLEMENT TO THE MENTAL (Philadelphia Insurance Companies)

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Completed 29 July 2020

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