Physical Therapy Professional Liability Insurance Occurrence Application

Transcription

1 CONNECTICUT UNDERWRITERS, INC. 421 Wadsworth St., P.O. Box 2784 Middletown, CT Inside CT Outside CT Fax CONEXCO 114 Turnpike Road, Suite 109 Westborough, MA Fax NEW HAMPSHIRE UNDERWRITERS 14 Dixon Avenue Concord, NH Fax Physical Therapy Professional Liability Insurance Occurrence Application 159 East County Line Rd., Hatboro, PA Tel: (860) Fax: (860) APPLICANT INFORMATION: a) Firm Name: b) Owner (s): Please indicate owner s practitioner certification: c) Contact Person: d) Doing Business as: e) Address: (city) (state) (zip) (county) f) Are all services provided from this location? Yes No If no, please attach separate sheet with addresses for additional locations. g) Phone: ( ) h) Fax: ( ) i) j) Annual Gross Receipts: k) Date Established / / PHY-A3SHMCT n) Type of Firm: Staffing/Registry Home Health Care Provider Rehab Clinic Other o) Is your firm incorporated? Yes No (i.e. Inc., P.C., LLC, P.A., Ltd., CORF, etc.) Please indicate: p) Is your firm a franchise? Yes No q) Do you anticipate a change in your operations within the next twelve months? Yes No If yes, please explain. r) Are there other entities / subsidiaries? Yes No If yes, please explain. s) Description of Operations: (attach separate sheet if necessary) l) Are you a member of any professional Association?.. Yes No Name: m) Please provide your firm's web address if applicable: t) Requested Effective Date of Policy / / (Must be within 60 days following application date.) Page 1 of 6

2 2. HIRING/SCREENING AND EMPLOYMENT PROCEDURES: a) Have the owners and/or employees/contractors ever been the subject of complaints, charges or disciplinary action for any reason, by a court, licensing board or regulatory agency responsible for maintaining the standards of your profession? Yes No If yes, please provide detailed documentation on a separate sheet. b) Do you verify certification and professional licensure status of employees and independent contractors?... Yes No d) Do you check employees/contractors references before hiring/placing? Yes No e) How are references checked? Written Verbal Both f) Do you question and utilize background checks for prospective employees/contractors regarding any past criminal record? Yes No c) Do you provide job descriptions for all professional and non-professional employees? Yes No 3. RISK MANAGEMENT AND QUALITY ASSURANCE: a) Are you licensed in all states where you operate?.... Yes No List all states of operation: b) Has your license ever been suspended, revoked, or voluntarily surrendered in any state? Yes No If yes, please provide details: c) Do you utilize a written Quality Assurance and Risk Management Program? Yes No If no, please explain: d) Do you have a Director of Quality Assurance and/or Risk Management? Yes No e) Do you place an informed consent document in the patient s medical records? Yes No f) Are you accredited by any government or other body? Yes No If yes, 1) JCAHO/CHAPS 2) Medicare/Medicaid 3) Other If no, please explain g) Are all employees trained before assignment? Yes No If no, please explain. h) Describe your educational training, certification and continuing education programs. (attach separate sheet if necessary) 4. CLAIMS HISTORY: a) Have any claims/suits ever been made against the applicant or employees/contractors? Yes No If yes, please provide loss run and details including date, amount paid, and reserve amounts for open claims. b) Are you or your employees/contractors aware of any circumstances which have occurred and may result in a claim against you? Yes No c) Have you or your employees/contractors been declined by any insurance company, cancelled or non-renewed?.... Yes No (Not applicable for MO residents) If yes, please provide detailed documentation, including loss history, on a separate sheet. 5. PREVIOUS PROFESSIONAL LIABILITY INSURANCE COVERAGE (PAST FIVE YEARS): Insurance Company Limits Effective Date Annual Premium Claims Made* Retro-Active Date or Occurrence *If you checked claims-made, please check the appropriate box on next page ---> Page 2 of 6

3 I have purchased the extended reporting period endorsement on my prior policy. Name of carrier: I wish to be considered for Prior Acts Coverage and have attached a copy of my certificate of insurance listing my current coverage limits, current carrier and retroactive date. I understand that approval for prior acts coverage is subject to approval by the Underwriter. I realize that unless I purchase Prior Acts Coverage which coincides with the retroactive date of my previous claims-made policy and have no extended reporting period endorsement that I will have a gap in coverage. I understand that I elected not to purchase the Extended Reporting Period Endorsement on my previous claims-made policy, and I also have elected not to purchase Prior Acts Coverage on my new claims-made policy. I understand that I will be uninsured for the period in which my prior claims-made policies existed. Furthermore, I understand that because of this there will be a gap in my insurance coverage. Name of Firm: 6. PROFESSIONAL LIABILITY SECTION a. EMPLOYEES/INDEPENDENT CONTRACTORS Profession # Full-Time # Part-Time Annual Hrs. Payroll Physical Therapist Physical Therapist Assistant Physical Therapy Aide Massage Therapist Athletic Trainers/Personal Trainer Occupational Therapist OTA/COTA Speech Therapist Speech Language/Hearing Therapist Speech Language Aide Pilates/Yoga Instructor Kinesiologist/Exercise Physiologist Rehabilitation Therapist Rehabilitation Assistant/Aide Respiratory Therapist Sports Medicine Therapist Medical Director Other Professions (List Professions/Job Titles) Other For additional professions not listed, please attach a separate sheet. b. What percentage of the above are independent contractors? Continued on next page ---> Page 3 of 6

4 c. LOCATION WHERE SERVICES ARE PROVIDED ( must equal 100%). d. TYPE OF SERVICES PROVIDED ( must equal 100%). e. STAFFING Patient Home Skilled Nursing Care Hospitals Home Care Nursing Home Nursing Homes Personal Care/Companion Hospital Clinics (No M.D./D.O.) Physical Therapy Clinics Doctor s Offices Respiratory Therapy Doctor s Offices Surgi/Emergi Center Ventilator Care Hospice/Assisted Living Center Infusion Therapy Your Own Home Chemotherapy Prison Trach Care School High Tech/Critical Care Rehabilitation Facility Wellness/Fitness Other (specify) Other (specify) f. Limits of Liability Requested: $1,000,000 per claim/$3,000,000 aggregate Other (specify) (May be subject to state specific guidelines) Name of Firm: (To Other Facilities for a Fee). ( must equal 100%). Other (specify) g. Does this firm provide any bed, board or overnight services? Yes No 7. GENERAL LIABILITY SECTION Page 3 of 5 Would you like to include the optional General Liability Coverage? Yes No (There is an additional charge for this coverage pending underwriter approval. Rate may vary due to additional location or higher limit request.) If yes, complete the section below and attach a separate sheet if necessary. a. Owned or leased premises: Address Own or Lease? b. Please list name and address or landlords or entities to be named as additional insureds and provide copies of current contracts PREVIOUS GENERAL LIABILITY INSURANCE COVERAGE (PAST FIVE YEARS): Insurance Company Limits Effective Date Annual Premium Claims Made Retro-Active Date or Occurrence Page 4 of 6

5 8. CONTRACTUAL AGREEMENTS Do you have written agreements with third parties? Yes No If yes, does each agreement include the following: A mutual indemnification/hold harmless agreement? Yes No A requirement that the other party carry liability insurance with liability limits equal to or exceeding yours? Yes No A statement for any service providers and independent contractors? Yes No A requirement for currently licensed/ appropriately qualified staff? Yes No Name of Firm: Page 4 of 5 9. SIGNATURE Insurance Agent: Michael J. Loughran Iowa License# IA241616; Florida License# A I have answered these questions to the best of my knowledge. I certify that I hold the highest credentials or standards appropriate for the healthcare profession for which I have applied as mandated by my state guidelines. I have not withheld information that would influence the judgment of the Insurance Company. My signing of this application does not bind the Company to complete this insurance. It is agreed that this Application shall be on file with the Company and that it shall be deemed to be attached to and made part of the policy, if issued, as if physically attached to the policy. I hereby represent that the aforementioned statements and answers are correct and complete. I further understand that an incorrect or incomplete statement or answer could void my insurance coverage. This application will be the basis of the contract if a Certificate of Insurance is issued. Once approved, I understand that there is no coverage in force until the premium is paid in full. I understand that a state mandated surcharge will be added to my annual premium if I am a resident of NJ (0.90%) or WV (0.55%). I have read and consent to the compensation terms below. FRAUD NOTICE Where Applicable Under The Law of Your State 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 or incomplete information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and may be subject to civil fines and criminal penalties (For District of Columbia residents only: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information, materially related to a claim, was provided by the applicant.) (For Florida residents only: 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.) (For Louisiana residents only: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.) (For Maine residents only: 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.) (For Maryland residents only: Any person who knowingly and willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly and willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.) (For New York residents only: and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.) (For Oklahoma residents only: WARNING: Any 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.) (For Pennsylvania residents only: 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.) (For Tennessee and Washington residents only: Penalties include imprisonment, fines and denial of insurance benefits.) (For Vermont residents only: 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 or incomplete information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which may be a crime and may be subject to civil fines and criminal penalties.) Name of Principal or Officer: (please print) Signature of Principal or Officer: Date: Agent/Broker Information: Agency Name: Contact Name: Address: (street) (city) (state) (zip) Telephone: ( ) Fax: ( ) Page 5 of 6

6 COMPENSATION and OTHER DISCLOSURE INFORMATION Healthcare Providers Service Organization (HPSO), a registered trade name of Affinity Insurance Services, Inc., exclusively offers the HPSO Program as an agent of CNA and provides services that may include the following: program marketing, underwriting, policy management, billing, risk management and client services on its behalf. Affinity Insurance Services Inc. is an insurance producer licensed in your state. Insurance producers are authorized by their license to confer with insurance purchasers about the benefits, terms and conditions of insurance contracts; to offer advice concerning the substantive benefits of particular insurance contracts; to sell insurance; and to obtain insurance for purchasers. The role of the producer in any particular transaction involves one or more of these activities. Compensation will be paid to the producer, based on the insurance contract the producer sells. Depending on the insurer(s) and insurance contract(s) the purchaser selects, compensation will be paid by the insurer(s) selling the insurance contract or by another third party. Such compensation may vary depending on a number of factors, including the insurance contract(s) and the insurer(s) the purchaser selects. In addition, Affinity may charge a fee for administrative services. Your signature on your application, quote form, check, and/or other authorization for payment of your premium, will be deemed to signify your consent to and acceptance of the terms and conditions including the compensation, as disclosed above, that is to be received by Aon. The insurance purchaser may obtain information about compensation expected to be received by the producer based in whole or in part on the sale of insurance to the purchaser, and compensation expected to be received based in whole or in part on any alternative quotes presented to the purchaser by the producer, by calling In addition, premiums paid by Clients to Affinity for remittance to insurers, Client refunds and claim payments paid to Affinity by insurance companies for remittance to Clients are deposited into fiduciary accounts in accordance with applicable insurance laws until they are due to be paid to the insurance company or Client. Subject to such laws and the applicable insurance company s consent, where required, Affinity will retain the interest or investment income earned while such funds are on deposit in such accounts. Aon Corporation, our ultimate parent company, and its affiliates have from time to time sponsored and invested in insurance and reinsurance companies. While we generally undertake such activities with a view to creating an orderly flow of capacity for our clients, we also seek an appropriate return on our investment. When they exist, these investments, for which Aon is generally at-risk for potential price loss, typically are small and range from fixed-income to common stock transactions. In such case, the gains or losses we make through our investments could potentially be linked, in part, to the results of treaties or policies transacted with you. Please visit the Aon web site at for a current listing of insurance and reinsurance carriers in which Aon Corporation and its affiliates hold any ownership interest. Contracts and Agreements Aon Corporation s operating affiliates are parties to numerous agreements with many insurance companies, including companies from which our clients have purchased insurance or reinsurance. Please visit for more detail on these agreements. Tel: Fax: This program is underwritten by American Casualty Company of Reading, Pennsylvania, a CNA company, and is offered through the Healthcare Providers Service Organization Purchasing Group. Coverages, rates and limits may differ or may not be available in all states. All products and services are subject to change without notice. CNA is a registered trademark of CNA Financial Corporation. Copyright 2012 CNA. All rights reserved. Nurses Service Organization and Healthcare Providers Service Organization are registered trade names of Affinity Insurance Services, Inc.; (AR ); in CA, MN & OK, AIS Affinity Insurance Agency, Inc. (CA ); in CA, Aon Affinity Insurance Services, Inc., (0G94493), Aon Direct Insurance Administrator and Berkely Insurance Agency and in NY and NH, AIS Affinity Insurance Agency. GSL7766 (1/07) A b Page 6 of 6

7 CONNECTICUT UNDERWRITERS, INC. 421 Wadsworth St., P.O. Box 2784 Middletown, CT Inside CT Outside CT Fax CONEXCO 114 Turnpike Road, Suite 109 Westborough, MA Fax NEW HAMPSHIRE UNDERWRITERS 14 Dixon Avenue Concord, NH Fax Physical Therapy Rehabilitation Supplemental Application Name of Company: 1. Are there physicians working under your company name? Yes No 2. If yes, is the physician an owner/partner? Yes No a. If not an owner/partner, what is their function under the business? 3. Please describe the services you provide: 4. Is the firm a Comprehensive Outpatient Rehabilitation Facility (CORF)? Yes No 5. Do you have a Medical Director? Yes No 6. If yes, is the Medical Director an employee or an independent contractor? Yes No a. Please describe the duties performed by the Medical Director: 7. Are there any Chiropractors on staff? Yes No 8. Do you provide wellness/fitness services? Yes No 9. Do you provide yoga or Pilates instruction outside of physical therapy treatment programs? Yes No 10. If yes, what percentage of the business revenue is generated from fitness services? % 11. Are the fitness services open to the public? Yes No 12. Do you have any subsidiaries? Yes No a. If yes, please provide the subsidiary name and address. Signature: Date: This program is underwritten by American Casualty Company of Reading, Pennsylvania, a CNA company, and is offered through the Healthcare Providers Service Organization Purchasing Group. Coverages, rates and limits may differ or may not be available in all states. All products and services are subject to change without notice. CNA is a registered trademark of CNA Financial Corporation. Copyright 2012 CNA. All rights reserved. Nurses Service Organization and Healthcare Providers Service Organization are registered trade names of Affinity Insurance Services, Inc.; (AR ); in CA, MN & OK, AIS Affinity Insurance Agency, Inc. (CA ); in CA, Aon Affinity Insurance Services, Inc., (0G94493), Aon Direct Insurance Administrator and Berkely Insurance Agency and in NY and NH, AIS Affinity Insurance Agency. Tel: Fax: A b