Business Name
Business Primary Address
Type Of Operation Medical (Physical therapy, monitoring vitals, skilled nursing, monitoring of health conditions)Non-Medical (Personal care services, companies care services, household assistance)
Mailing Address Check if it is the same as the business address. If not, enter below:
Number of Full-Time Employees
Number of Part-Time Employees
Is business a startup? YesNo If no, years of operation? # of years
Annual Revenue $ USD
Does business currently have insurance? YesNo
Effective Date Requested
Does the applicant have any operations not included in the medical or non-medical home care definition?
YesNo
Are 100% of services provided in private homes?
If not, please indicate % of operations in each:
% Private Homes
% Hospitals
% Nursing Homes
% Assisted Living
% Medical Clinic
% Other
We are seeking professional liability insurance for home health care.
Our professional employees and/or independent contractors are each properly licensed or certified in accordance with applicable state and federal regulations. YesNo
Do you have any physicians on staff, other than a medical director, that performs any direct patient care? YesNo
We require all employed or contracted licensed drivers to maintain personal auto liability insurance with limits of liability of at least the state required minimum and verify their compliance. YesNo
We check motor vehicle records (MVR) of all staff prior to employment and annually. YesNo
Number of employees who are driving during their course of work.
Do any drivers have 2 or more traffic violations? YesNo
Are criminal background checks completed on all employees and/or independent contractors? YesNo
Are abuse registry checks completed on all employees and/or independent contractors? YesNo
Do you need to name an individual or organization as an additional insured?
If yes, fill out below. If not, please skip
Name
Address
Subsidiary?
Does the applicant have any current knowledge of any incident or circumstance that could reasonably be expected to give rise to a claim for the proposed insurance coverage?
Has the applicant had any incident or circumstance that has given rise to an insurance loss?
I attest that we do NOT provide services related to exposed tracheotomy, ventilators, feeding tubes, stage 1 wound care management, >10% pediatric patients, correctional health, or hospital exposures. We do NOT perform any services in the states of Hawaii or Alaska. We cannot provide coverage for these operations.
By checking this box, you attest that the statement to the left is true or false. YesNo
Signature
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