PROFESSIONAL & GENERAL LIABILITY INSURANCE APPLICATION FOR GROUP HOMES / HOME HEALTH Legal Name of Applicant:* Phone Number:*Fax Number:Email:* Physical Address:* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country If multiple names and locations, please list:Date Established:* Type:* Corporation Partnership Professional Assoc. Individual In what states is the Applicant registered and licensed to practice?* Please list all subsidiaries to which this insurance will apply. Include a complete description of the operations of each subsidiary with confirmation that this Application reflects all exposures.*Is the firm engaged in, owned by, associated with or controlled by any other business?* Yes No If yes, please provide details:Professional Activities and Specialty (Attach narrative description if necessary). Select One:* Alcohol/Drug Rehabilitation Mental Health Day Care Methadone Treatment Day School (Mental Health/Retardation) Physical/Developmental Disability Facility Family Planning/Crisis Pregnancy Psychiatry Foster Care/Adoption Agency Respite Care Group Home Shelter Hotlines (Phone Crisis Center) Sheltered Workshop Meals on Wheels Social Services Mental Health Facility Transitional Living State approximate division of Applicant’s clients among:Alcoholics %* Counseling/Family Planning %* Drug Addicts %* Mentally Retarded %* Minors under age 18 %* Psychiatric %* Senile or Aged %* Are There Any Employees or Volunteers Working for the Applicant?* Yes None List the number of each type of Applicant’s employees and volunteers:Analyst Counselor/Therapist Psychoanalyst Psychologist Psychotherapist Psychiatrist Physiotherapist Social Worker Other (specify): Does the psychiatrist(s) above maintain their own insurance? Yes No If Yes, what are the limits? Are all of the employees and/or volunteers listed licensed in accordance with applicable state and federal regulations?* Yes No Provide explanation:Are There Any Independent Contractors Who Provide Professional Services on behalf of the Applicant?* Yes None List the number and type of independent contractors:*Are all of the independent contractors listed licensed in accordance with applicable state and federal regulations?* Yes No Provide explanation:Has the Applicant or any of the individuals listed as employees, volunteers, or independent contractors:Ever been the subject of disciplinary or investigative proceeding or reprimand by a governmental or administrative agency, hospital or professional association? Yes No If yes, provide a detailed explanation:Ever been convicted for an act committed in violation of any law or ordinance other than traffic offenses? Yes No If yes, provide a detailed explanation:Ever had any state professional license or license to prescribe or dispense narcotics refused, suspended, revoked, renewal refused or accepted only on special terms or ever voluntarily surrendered same? Yes No If yes, provide a detailed explanation:Please provide the following information:Number of Licensed Beds:* Number of Occupied Beds:* Number of Occupied Beds for Detox:* How many meals are served/delivered annually?* For Sheltered Workshop/Day School or Adult Day Care: Number of participants:* For Adoption Agency/Foster Care:Number of placements: Number of placements with parents: For Hotline/Phone Crisis Center:Number of calls annually: Does the Applicant provide any medical treatment?* Yes No If yes, provide details:State sources and amounts of total revenue for each source: Charitable ContributionsAmount Last Policy Year Est. ($)Amount This Policy Year ($)Government FundingAmount Last Policy Year Est. ($)Amount This Policy Year ($)Fee for ServicesAmount Last Policy Year Est. ($)Amount This Policy Year ($)Other (Specify)Type & Amount Last Policy Year Est. ($)Type & Amount This Policy Year ($) Totals*Total Amount Last Policy Year Est. ($)Total Amount This Policy Year ($)Number of estimated client/patient encounters in the last 12 months:* Note: “client/patient encounters” refers to number of visits – not number of client/patientsNumber of estimated client/patient encounters and client/patient services or tests in the next 12 months:* Describe Professional Liability coverage for the last five years for the firm:CarrierLimitDeductibleClaims Made or OccurrencePremiumExpiration (Mo/Day/Yr) If the expiring policy is claims made, what is the retroactive date? Has any insurer cancelled or refused to renew any similar insurance during the past five years?* Yes No If Yes, please describe:Is the Applicant currently insured under a Commercial General Liability Policy?* Yes No If Yes, please describe:CarrierLimitDeductibleClaims Made or OccurrencePremiumExpiration (Mo/Day/Yr) If the expiring policy is claims made, what is the retroactive date? Has any application for Professional Liability or General Liability Insurance made on behalf of the firm, any predecessors in business or present Partners ever been declined or has the insurance ever been cancelled or renewal refused?* Yes No If Yes, please provide details:Has any claim ever been made against the firm or any of its employees?* Yes No If Yes, please submit currently valued carrier loss runs for the past 5 years and attach details stating: 1) date when claim was made; 2) date the act giving rise to the claim was committed; 3) name of the claimant; 4) nature of the claim; 5) amount involved including reserves; and 6) final disposition.Has the Applicant ever been audited or investigated with regard to Medicare/Medicaid billing practices or utilization of Medicare/ Medicaid services?* Yes No Been accused of errors by any government agency or commercial payer?* Yes No In the last five (5) years, have you experienced any claims or are you aware of any circumstances that may give rise to a claim that would have been covered by this policy?* Yes No Limits of Liability requested:* Deductible:* Desired term of policy - From:* - To:* The undersigned declares that to the best of his/her knowledge the statements herein are true. Signing of this Application does not bind the undersigned to complete the insurance, but it is agreed that this Application shall be the basis of the contract should a Policy be issued, and this Application will be attached and become a part of such Policy, if issued. Underwriters hereby are authorized to make any investigation and inquiry in connection with this Application as they may deem necessary. It is warranted that the particulars and statements contained in the Application for the proposed Policy and any materials submitted herewith (which shall be retained on files by Underwriters and which shall be deemed attached hereto, as if physically attached hereto), are the basis for the proposed Policy and are to be considered as incorporated into and constituting a part of the proposed Policy. It is agreed that in the event there is any material change in the answers to the questions contained herein proper to the effective date of the Policy, the Applicant will notify Underwriters and, at the sole discretion of Underwriters, any outstanding quotations may be modified or withdrawn. For purposes of creating a binding contract of insurance by the Application or in determining the rights and obligations under such a contract in any court of law, the parties acknowledge that a signature reproduced by either facsimile or photocopy shall be the same force and effect as an original signature and that the original and any such copies shall be deemed one and the same document. Signatory statement agreement:* Yes, I have read and agree to the signatory statement. Signature*Name* First Last Date* MM slash DD slash YYYY PhoneThis field is for validation purposes and should be left unchanged.
