THOMCO Allied Health Insurance Application Note: All questions must be answered or application will be returned

Transcription

1 THOMCO Allied Health Insurance Application te: All questions must be answered or application will be returned Effective Date Requested: APPLICANT INFORMATION: Date Quotation Desired: Name (Legal Entity): DBA: (List all legal entities to be considered for insurance, including the interests) Federal ID #: Web Site Years in business under current ownership Type of Entity: Corporation Individual Partnership Joint Venture LLC Contact Name: Address: Mailing Address: Phone: Fax: Is the applicant licensed in all states in which it is operating? List States of Operation(s) POLICY INFORMATION: Is this a renewal? Is this policy being non-renewed? Current Carrier? Current Limit of Insurance (GL & PL)? Expiring premium? What General Liability/Professional Liability limit of insurance do you want to purchase? $100,000/$300,000 $250,000/$500,000 $250,000/$750,000 $500,000/$500,000 $1,000,000/$1,000,000 $1,000,000/$2,000,000 $1,000,000/$3,000,000 $1,000,000/$6,000,000 $2,000,000/$4,000,000 $3,000,000/$5,000,000 $3,000,000/$6,000,000 $500,000/$1,500,000 $2,000,000/$2,000,000 Please select the desired GL/PL Deductible Limit: $1,000 $2,500 $5,000 $7,500 $10,000 $25,000 Retro Date for PL Claims Made (mm/dd/yyyy) Do you want General Liability quoted on a Claims Made or Occurrence basis? Claims Made Occurrence Retro Date for General Liability (mm/dd/yyyy) Please select a limit for Defense outside the limits: Coverage Capped at Full Limit Capped at 1/2 Limit Please select the desired sub-limit for Abuse: Coverage $100,000 /$300,000 $500,000/$500,000 $1,000,000/$1,000,000 AUTOMOBILE INFORMATION: Please complete the AUTOMOBILE SUPPLEMENTAL APPLICATION. Please select the desired automobile coverage: Coverage n-owned Auto Only Hired & n-owned Auto Please select the desired Limits: $100,000 $250,000 $500,000 $1,000,000 Do you want Employee Benefits Liability coverage of $1,000,000 / $1,000,000 limits? Retro Date for Employee Benefits Liability coverage

2 THOMCO Allied Health Insurance Application - page 2 te: All questions must be answered or application will be returned Does your agency have a written credentializing and procedure for all individuals associated with or practicing with the agency? Do you conduct pre-employment screening and investigation? Does the staff supervisor make regular audit visits of staff in the field? Do you require contracted staff (if any) to carry their own Professional Liability Insurance? Is the applicant and all professional employees licensed in accordance with applicable state and federal laws? Does any proposed insured have any knowledge of an event, circumstance or occurrence prior to the effective date of the proposed policy, or does any proposed insured foresee that a claim may be brought as a result of said event, circumstance or occurrence? List all losses in the past 4 years whether or not insured(attach additional sheet if necessary) Include any crimes occurred or attempted on your premise : Date of Claim Description of Claim Open/Closed Paid $ Reserve $

3 AUTOMOBILE LIABILITY SUPPLEMENT Do employees or independent contractors use their vehicles on your behalf? Do you verify insurance coverage? Do employees and independent contractors use their own vehicle to transport patients? Do employees and independent contractors transport non-ambulatory patients? Are vehicles equipped with wheelchair locks/lifts? Are certificates of insurance obtained and maintained in file? What limits of insurance are required by the applicant of the employees and independent contractors to be maintained? State Minimum Higher than State Minimum Does the applicant obtain MVR's prior to employment and annually thereafter? Does the applicant allow drivers who have been convicted of DWI, DUI or Vehicular Manslaughter to drive on their behalf? Are any drivers under the Age of 21 or over the Age of 70 allowed to drive? Do you allow personal use of your vehicles? Please describe:

4 LOCATION SUPPLEMENT te: Complete one supplement for Each Location Location #: Location Address: GENERAL BUSINESS INFORMATION: What Services do you provide at this location? (Select all that apply) Home Health Hospice Companion Care Provider Physical Therapy Clinic Pharmacy Consultants Pregnancy Centers Artificial Limb Clinics Nurse Registry Adult Daycare Surgery Centers Optical Medical Clinic Medical Labs Ocularists Medical Staffing * Oncology Treatment Visiting Nurse Agency Medical Equipment Supplier Diagnostic Imaging & X-Ray Dialysis Centers Medical Arts Schools Other Services * Describe types of Medical Staffing: For Home Health, Hospice or Companion Care Providers, provide Annual Total Gross Receipts: OTHER EXPOSURES: Total annual hours of service for all employees/contractors (Do not include administrative staff): ADDITIONAL INSURED/LOSS PAYEE EXPOSURES: If your landlord, bank or leasing company requires to be shown on your policy, please complete the following: Name: Address: Additional Insured Loss Payee Both Insured Type: Designated Person Franchisor Lessor of Equipment Landlord Other: Describe: What line(s) of business does this exposure apply: General Liability Professional Liability Both Name: Additional Insured Loss Payee Both Address: Insured Type: Designated Person Franchisor Lessor of Equipment Landlord Other: Describe: What line(s) of business does this exposure apply: General Liability Professional Liability Both SERVICES AND STAFFING EXPOSURES: Location of services provided (Total of all Services must equal 100%) Private Homes % Clinics or n-private Homes % Doctor's Office % Hospitals % Owned Facility % Other(specify): % Types of services provided (Total of all Services must equal 100%) Personal Care/Companion % Home Health % Skilled Nursing % Rehabilitation Therapy % Medical Equipment Supply % Counseling/Clergy % Supplemental Staffing % Respiratory Therapy % Closed Pharmacy % Hospice % HIV % Infusion Therapy/Chemo % Retail Pharmacy % Trach/Ventilator % Pediatric Care % Palliative % Other(specify): %

5 Print Form HOME HEALTH, HOSPICE AND COMPANION CARE SUPPLEMENT te: All questions must be answered or application will be returned SUBMISSION REQUIREMENTS: The following information must be received prior to binding coverage and may not apply to all entities: 4 Years of currently valued loss runs and list of potential claims (incidents) from the retro date forward. Brochure, if available Most recent copy of federal survey reports and plan of correction (routine survey activity) Most recent copy of state licensure survey and plan of correction (routine survey activity) Copy of all federal and state complaint investigation reports in the last 12 months and plan of correction(s) Most recent accreditation survey Current Financials (audited are preferable), if account is over $100,000 in premium Has the applicant's license ever been suspended, revoked, voluntarily surrendered or undergone enforcement action? If yes, please explain: Has the applicant been under investigation by the OIG; FBI; Department of Justice or by the State or Local Authorities? If yes, please explain: Are Companion Care providers certified through NAHC or State Certified Program? What is your average staff turnover rate(combined)? Do all Contracts with pharmacies, DME suppliers, hospitals, nursing homes & Assisted Living Facilities include a hold harmless agreement? Are complete records kept on all patients? Are they stored in locked cabinets? Do Patient records include the following? (check yes to all that apply) Complete treatment plan prescribed by the physician, including follow up plans Assessments of patients-prior to & after accepting the patient If yes, how often Patient Care/home visits documentation Documentation of all self-homecare training All changes in condition or incidents documentation to the physician & family A copy of physician referral, including certification that the patient has less than 6 months to live Copies of the patients signed informed consent Medications & dosage, including documentation of administering medications A copy of all literature given to clients explaining services, fees, etc. Patients rights/explanation to family Termination of services and discharge criteria Advance directives /Living wills/durable Power of Attorney MEMBERSHIPS: Is the applicant Medicare certified? Is the applicant a member of any of the following organizations/accreditions? (Select all that apply and provide the member number): NAHC Member #: HIDA CHAP JCAHO NHPCO OTHER

6 HOME HEALTH, HOSPICE AND COMPANION CARE SUPPLEMENT - page 2 HIRING / SCREENING: Check all methods used in hiring all employees/ independent contractors: Criminal Background Checks Federal State Personal Interview Reference Checks Validate Education Verify Current Certification/Professional Licensure Validate Work History Drug Testing Are the above maintained in employee file? Are the above methods done prior to hiring? Are job descriptions provided for all professionals and non-professionals? Do you verify certification/licensure status of employees & individual contractors? Do you verify if any potential employee has ever had their license revoked or suspended, or had disciplinary action taken against them? Are employees required to carry their own insurance? What limits are required? Are independent contractors required to carry their own insurance? What limits are required? Are certificates of insurance for independent contractors maintained on file & obtained each year? RISK MANAGEMENT: Does the applicant utilize a formal written Quality Assurance and Risk Management Program? Does the applicant have a formal Compliance Program? Does the applicant have a formal Safety Program? Is the overall responsibility for Risk Management handled by one person? Name: Does the applicant have a formal drug handling/documentation/storage/disposal procedure in place? Does the applicant obtain patient/client surveys? Does the applicant have a formal incident reporting procedure in place? Is there peer or committee review of incident reports? Does the applicant have formal HIPAA compliance procedures in place? Are supervisors available at all times in the event of an emergency? Does the applicant have formal documented training in place for the following? ( Check all that apply) Crisis Management Disposal of Medical Waste First Aid Safe Listing, Transferring and Ambulating Safe Use of Equipment Infusion Therapy

7 Print Form MEDICAL STAFFING SUPPLEMENT Submission requirements: 4 year Hard Copy loss runs; Current Financials; and Brochure, if Available Annual Gross Receipts: Estimated next twelve months: Last Twelve Months: Enter percentage of services provided by category of staff including contracted staff: Hospitals % Nursing Homes/Assisted Living % Jail/Prison/Correctional Work % Private Doctors % Private Home Care/Home Health % Other (Specify): % Does your agency have a written credentialing policy and procedure for all individual's associated with and/or practicing within the agency? Do you conduct Pre-employment screening and investigation? Does the staff supervisor make regular audit visits of staff in the field? Do you require contracted staff (if any) to carry their own Professional Liability Insurance? Do you secure Certificates of Insurance as evidence of such coverage? Is the applicant and all professional employees licensed in accordance with applicable state and federal laws? Has the applicant or any of its employees: Ever been the subject of disciplinary or investigatory proceedings or reprimanded by an administrative or governmental agency, hospital or professional association? Had any professional license refused, suspended, revoked, renewal refused or accepted only with special terms or has applicant or any of its employees voluntarily surrendered any professional license? Been convicted for an act committed in violation of any law or ordinance other than traffic offenses? Is any staff provided to hospitals specifically to serve a particular specialty ( i.e. OR, ICU, CCU, ER, etc.) Enter the percentage of services provided by category of staff including contracted staff: OR % Labor/Delivery % ICU/CCU % ER % Other(specify) % Do you prepare job descriptions and instructional manuals for your staff? Do you maintain records of specific areas of expertise of each staff member? Do you require staff to report all incidents (accidents) which might result in a liability claim AND are records of such records kept on file by you? Do you enter into any contractual agreements (other than lease of premises agreements) in which you hold others harmless? TH APP AH MSTF 001

8 SIGNATURE SUPPLEMENT GENERAL FRAUD STATEMENT: Any person who knowingly and with intent to defraud any insurance company or another 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 the person to criminal and (NY: substantial) civil penalties. In the District of Columbia, Louisiana, Maine, Tennessee and Virginia, and Washington insurance benefits may also be denied. NOTICE TO COLORADO APPLICANTS: THIS NOTICE IS A PART OF YOUR APPLICATION FOR PROFESSIONAL LIABILITY INSURANCE: 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 info. NOTICE TO FLORIDA APPLICANTS: 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 of the third degree. NOTICE TO HAWAII APPLICANTS: For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or benefit is a crime punishable by fines or imprisonment or both. NOTICE TO OHIO APPLICANTS: Any person who, with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud. NOTICE TO OKLAHOMA APPLICANTS: WARNING: A person who knowingly and with intent to injure, defraud, or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony. NOTICE TO OREGON APPLICANTS: Any person who knowingly and with intent to defraud or solicit another to defraud the insurer by submitting an application containing a false statement as to any material fact, may be violating state law. NOTICE TO VERMONT APPLICANTS: Any person who knowingly and with intent to defraud any insurance company or another person files an application for insurance containing any materially false information or conceals for the purpose of misleading information concerning any fact material thereto, may be committing a crime, subjecting the person to criminal and civil penalties. THE APPLICANT DECLARES THAT THE STATEMENTS SET FORTH HEREIN ARE TRUE. THE APPLICANT AGREES THAT IF THE INFORMATION SUPPLIED ON THE APPLICATION BY THE APPLICANT CHANGES BETWEEN THE DATE OF THE APPLICATION AND THE EFFECTIVE DATE OF INSURANCE, APPLICANT WILL IMMEDIATELY NOTIFY THE COMPANY OF SUCH CHANGES AND THE COMPANY MAY WITHDRAW OR MODIFY ANY OUTSTANDING QUOTATIONS AND/OR AUTHORIZATION OR AGREEMENT TO BIND THE INSURANCE. Applicant's Signature: Producer's Signature (Only applicable if using a producer) Producer's License Number Date: Date: Exp. Date: