POST MORTEM SERVICES Supplemental Application

Transcription

1 POST MORTEM SERVICES Supplemental Application Rockwood Programs, Inc Philadelphia Pike Claymont, DE Tel: Fax: This is an application for claims-made insurance. It is important that you report any currently known facts, incidents, situations or circumstances that could result in a claim to your current insurer or purchase an extended reporting period endorsement to cover such known facts, incidents, situations or circumstances. Protective Specialty Insurance Company will not provide coverage for known facts, incidents, situations, circumstances or claims of which you are aware prior to the inception date of this coverage. Instructions for completing this application: 1. Please answer all the questions. This information is required to make an underwriting and pricing evaluation. Your answers hereunder are considered legally material to that evaluation. 2. If a question is not applicable, state N/A. If more space is required to answer a question, please attach an exhibit with the question number. 3. The application must be signed and dated by a named insured or authorized person. 4. PLEASE ATTACH THE FOLLOWING: a. Brochures or other descriptive literature about the applicant s services or operations. b. Resume of principals or officers and key professional staff. c. A copy of your letterhead. d. Supplemental application(s) if applicable. 5. Return this and all supplemental applications to to: the insurer at: submission@protectivespecialty.com sales@rockwoodinsurance.com OR Protective Rockwood Specialty Programs, Insurance Inc. Company 3001 Philadelphia Pike Claymont, DE Proposed Effective Date: From to All questions MUST be completed in full. If space is insufficient to answer any question fully, attach a separate sheet. 1. Full name of Applicant: 2. (a) Services provided by the Applicant and percentage of gross revenues derived: Percentage (i) Embalming [ ] Yes [ ] No % (ii) Cremation [ ] Yes [ ] No % (iii) Funeral Director [ ] Yes [ ] No % (iv) Funeral Home [ ] Yes [ ] No % (v) Cemetery [ ] Yes [ ] No % (vi) Pre-Need Sales [ ] Yes [ ] No % (vi) Casket and Other Product Sales [ ] Yes [ ] No % (vii) Other (specify) % TOTAL 100% (b) If only embalming and cremation services are provided answer the following.

2 (i) Is the Applicant an owner of or an employee of a funeral home?... [ ] Yes [ ] No If Yes, provide the name of the funeral home and advise of the general and professional liability insurance and limits of liability they maintain. (ii) Does the embalmer have a contract with any funeral home? [ ] Yes [ ] No If Yes, provide the name of the funeral home and advise of the general and professional liability insurance and limits of liability they maintain. (c) If any pre-need sales are provided answer the following: (i)... Are pre-need sales insured? (ii) If No, provide complete details of how such sales are financed. (iii) If Yes, provide the names of all insurance companies that insurance is placed with. (iv) Attach a copy of the Applicant s insurance license(s). 3. Does the Applicant contract with any out of state funeral homes?... [ ] Yes [ ] No If Yes, list the states. 4. Is the Applicant responsible for: (a) (b) (c) picking up remains from hospitals, hospices or nursing homes?... [ ] Yes [ ] No shipping remains out of state?... [ ] Yes [ ] No picking up remains from any means of transportation?... [ ] Yes [ ] No 5. Is the Applicant licensed in all states where services are performed?... [ ] Yes [ ] No 6. Where are embalming services done: Percentage (i) At the embalmer s own facility? [ ] Yes [ ] No % (ii) At another location? (specify) [ ] Yes [ ] No % 7. How many bodies are handled per year? 8. Describe the procedures that are used to ensure that bodies are given the pre-arranged post mortem treatment. 9. Attach a copy of the consent form used by the embalmer to obtain the family s permission to cremate remains (if applicable). Please provide additional comments that would further clarify the information above or address characteristics of your practice not specifically addressed herein.

3 SIGNATURE By signing this application, you represent and agree to each of the following four (4) items: 1. You have made a comprehensive internal inquiry or investigation to determine whether anyone in your company is aware of any actual or alleged fact, circumstance, situation, incident, act, error or omission which may reasonably be expected to result in a claim, and have fully and completely divulged any and all such situations in the Claim Activity section of this application; and 2. Each of the statements and answers given in this application, and any supplemental applications, are: a. Accurate, true and complete to the best of your knowledge and no material facts have been suppressed or misstated; b. Representations you are making on behalf of all persons and entities proposed to be insured; c. A material inducement to the insurance company to provide insurance, and any policy issued by the insurance company is issued in specific reliance upon these representations. 3. This application, along with any supplemental applications, are hereby deemed to be attached to the policy and incorporated into the policy, whether or not any of the supplemental applications are physically attached to a particular copy of the policy, and regardless of whether any of the supplemental applications are signed or dated. 4. You agree to promptly report to the Company, in writing, any material change in your operations, conditions, or answers provided in this application, or in any supplemental application, that may occur or be discovered after the completion date of said application(s), but before the inception date of the policy. Upon receipt of any such written notice, the Company has the right, at its sole discretion, to modify or withdraw any proposal for insurance. FRAUD WARNING: Any person who knowingly and with the 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 purposes of misleading information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects the person to criminal and civil penalties. NOTICE TO COLORADO APPLICANTS: 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 POLICY HOLDER OR CLAIMANT FOR THE PURPOSE OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE POLICY HOLDER 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.

4 NOTICE TO FLORIDA APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY INSURANCE COMPANY FILES A STATEMENT OF CLAIM CONTAINING ANY FALSE, INCOMPLETE, OR MISLEADING INFORMATION IS GUILTY OF A FELONY OF THE THIRD DEGREE. NOTICE TO MARYLAND AND LOUISIANA APPLICANTS: ANY PERSON WHO KNOWINGLY AND WILLFULLY 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. NOTICE TO MAINE, TENNESSEE, VIRGINIA AND WASHINGTON APPLICANTS: 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, AND DENIAL OF INSURANCE BENEFITS. NOTICE TO NEW JERSEY APPLICANTS: ANY PERSON WHO INCLUDES ANY FALSE OR MISLEADING INFORMATION ON AN APPLICATION FOR AN INSURANCE POLICY IS SUBJECT TO CRIMINAL AND CIVIL PENALTIES. NOTICE TO ARKANSAS AND NEW MEXICO APPLICANTS: ANY PERSON WHO KNOWINGLY PRESENTS A FALSE 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 CIVIL FINES AND PENALTIES. NOTICE TO OKLAHOMA APPLICANTS: 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. IMPORTANT NOTICE: Failure to report any claim made against you during your current policy term, or facts, circumstances or events which may give rise to a claim against you to your current insurance company BEFORE expiration of your current policy term may create a lack of coverage. Please see IMPORTANT NOTICE in the Claim Activity section above. COMPLETION OF THIS FORM DOES NOT BIND COVERAGE. APPLICANT S ACCEPTANCE OF COMPANY S QUOTATION IS REQUIRED PRIOR TO BINDING COVERAGE AND POLICY ISSUANCE. IT IS AGREED THAT THIS FORM SHALL BE THE BASIS OF THE CONTRACT SHOULD A POLICY BE ISSUED, AND IT WILL ATTACH TO THE POLICY. An authorized representative who is an active owner, officer or partner of your firm must sign this application within thirty (30) days prior to the policy inception date.

5 If additional space is needed, please provide details on a separate attachment. I understand the information submitted herein becomes a part of my professional liability insurance application and is subject to the same warranties and conditions. Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act. Signature of Owner, Officer or Partner Date Printed or Typed Name and Title