Home Healthcare

1. Name of Business: *
2. Mailing Address: *
2. a) Email Address: *
3. Location Address:
(If multiple name and locations, please attach list)
4. Telephone Number: *
Fax Number:
5. a) Date Established or Date of Birth (if applicant is an individual)
5. b) Entity Type: Corp.
Partnership
Prof. Assoc.
Individual
LLC
Solo Practitioner
5. c) For Profit
Non-Profit
6. Percentages of revenue for the past year:
Medicare
Medicaid
Government Funding
Fee for Services
Other specify
7 a) Desired Effective Date:
b) Desired Limits of Liability: $
/$
c) Desired Deductible: $
8. a) Gross Receipts for the Past 12 Months: $
b) Gross Receipts Estimated for the Next 12 Months: $
c) Patient encounters in the last 12 months: (patient encounters refers to number of visits – not number of patients)
d) Patient tests carried out in the last 12 months:
e) Estimated patient encounters in the next 12 months
f) Estimated patient tests carried out in the next 12 months
9. Entity is a: Home Health Agency (medical services provided)
Home Health Agency (only non-medical services provided)
Medical Personnel Staffing/Nurse Registry for Home Health Care Services Only
Medical Personnel Staffing/Nurse Registry (Other than Home Health Care)
Other (please describe)
10. Full description of services provided:
11. Does the applicant have any ancillary operations not stated above?
Yes
No
If yes, please provide details:
12. Is the firm engaged in, owned by, associated with or controlled by any other business? If yes, give detail.
13. a) List the number and type of applicant's employees estimated over the next 12 months. If none, state none.
Registered Nurse
Licensed Practical Nurse
Physical Therapist
Occupational Therapist
Respiratory Therapist
Speech Therapist
Nurse Practitioner
Physician Assistant
Physician (patient contact)
Physician (medical director only)
Aide/Homemaker
Social Worker
Pharmacists
Clerical/Admin
Other (please describe)
13. b) List the number and type of independent contractors estimated over the next 12 months. If none, state none.
Registered Nurse
Licensed Practical Nurse
Physical Therapist
Occupational Therapist
Respiratory Therapist
Speech Therapist
Nurse Practitioner
Physician Assistant
Physician (patient contact)
Physician (medical director only)
Aide/Homemaker
Social Worker
Pharmacists
Clerical/Admin
CRNA/Surgical Technician
Other (please describe)
c) Are all the above individuals licensed in accordance with applicable state and federal regulations
Yes
No
If no, provide details.
14. Do you require contracted staff (if any) to carry their own Professional Liability Insurance & secure certificates of Insurance as evidence of such coverage?
Yes
No
If yes, at what limits? $
/$
If no, is coverage desired with shared limits on this policy?
Yes
No
15. a) Enter where services are provided, broken down by percentage for each category, by employees & independent contractors:
Private Homes
Hospitals
Nursing Homes
Assisted/Independent Living
Medical Clinics/Private Doctors
Other (please describe)
15. b) State approximate division of applicant's patients among:
a. Alcoholics
b. Psyschiatric
c. Communicable
d. Dental
e. Drug addicts
f. General
g. Hemodialysis
h. Holistic medicine
i. Medical
j. Mentallly retarded
k. Obstetrical
l. Pediatric
m. Counseling/family planning
n. Research or experimental
o. Senile or aged
p. Stress Testing
q. Surgical
r. Tubercular
s. Other (please specify):
16. For Medical Personnel Staffing Agencies, enter which departments/areas are staffed broken down by percentage (please estimate if this is a start-up):
Emergency Room
Urgent Care
Labor & Delivery Rooms
Intensive Care Unit
Operating Room
Other (please describe)
17. a) Enter the percentages for the following exposures based on total services provided (please estimate if this is a start- up):
IV Therapy
Live-in Services
Pediatric/Infant Childcare
Cardiac Care
Respiratory Support
a. Acupuncture or acupuncture anesthesia?
b. Angiography/arteriography/venography?
c. Catheterization (other than urinary or umbilical)?
d. Closed reduction of compound fractures and/or nornal deliveries and/or dermabrasion?
e. Injection of radioisotopes and/or use of irradiated substances?
f. Radiation therapy and/or chemotherapy?
g. Psychiatric shock therapy?
h. Silicone injections?
i. Laser treatments?
j. Hypnosis?
k. Spinal anesthesia (other than saddle blocks or caudals)?
l. Other
17. b) Does the applicant perform:
a. Surgery other than an incision of superficial boils or suturing superficial fascia?
Yes
No
b. Circumcisions and/or dilation and curettage and/or insertion of temporary pacemakers?
Yes
No
c. Obstetric procedures?
Yes
No
d. Cosmetic plastic surgery?
Yes
No
e. Excision of large cysts and/or I&D of deep-seated boils or carbuncles?
Yes
No
f. Hysterectomies?
Yes
No
g. Open reduction of fractures?
Yes
No
h. Surgery for weight reduction of patients?
Yes
No
i. Silicone implants?
Yes
No
j. Sterilization procedures?
Yes
No
k. Biopsies and/or endoscopies?
Yes
No
l. Sex Change operations?
Yes
No
m. Other surgery?
Yes
No
if Yes to any of the above, please describes:
17. c) Does the applicant perform hospital emergency room care:
a. for its own regular patients?
Yes
No
b. for patients not own?
Yes
No
c. if answer to b. is Yes, please specify
the percentage of time devoted to this works:
the number of hours per month devoted to this work:
17. d) Does the applicant use drugs for weight reduction of patients?
Yes
No
If Yes, please describe a list of the drugs used and advise: percent of practice devoted to weight reducton, frequency and duration of prescriptions for weight reduction drugs and quantity dispensed by applicant
17. e) Does the applicant administer any methadone treatment?
Yes
No
If YES, please describe treatment and controls used and indicate number of treatments used during last 12 month and the next 12 months
17. f) Is anesthesia (other than topical or by means of local infiltration) administered by either applicant or others?
Yes
No
If YES, please detailed explanation.
17. g) State number of x-ray machines owned or operated and whether they are used for diagnosis or treatment or both. State by whm the treatment is given and number of procedures:
18. Does the applicant provide any beds for overnight stays or provide any treatment or services on their premises? If yes, give details:
19. Do you sell, rent or otherwise provide any equipment to products or others? If yes, give details including types of products & gross receipts from each:
20. Do you provide any legal and/or financial services and/or act as legal guardian or power of attorney for anyone? If so, please provide details:
21. Are patients accepted for health care services only upon a written plan of treatment established by an attending physician?
Yes
No
If no, give details:
22. a) Do you conduct pre-employment screening and investigation?
Yes
No
b) Do you question prospects about previous claims or suits?
Yes
No
c) Are employees required to actively participate in continuing education?
Yes
No
d) Do you prepare job descriptions and instructional manuals for your staff?
Yes
No
e) Do you have a written incident/occurrence reporting policy and procedures?
Yes
No
23. Check all the following that apply if obtained, verified & kept on file as part of the employee hiring & screening process:
Applications
Drug / HIV/ Hepatitis Testing
Education/Training/Competence
Criminal Background Checks
Licenses Held
Multi-State Registry
24. Is the applicant a member of any association or certified or accredited by any governing body? If yes, give details:
25. Any "YES" Answer Provide Details:
a) Ever been the subject of disciplinary or investigative proceedings or reprimand by a governmental or administrative agency, hospital or professional association?
Yes
No
b) Ever been convicted for an act committed in violation of any law or ordinance other than traffic offenses?
Yes
No
c) Ever been treated for alcoholism or drug addiction?
Yes
No
d) 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
26. Does the applicant own (wholly or in part), operate, or administer any hospital, nursing home or other institution where medical services are customarily rendered?
Yes
No
If yes, give details, including name, location size and number of beds.
27. Give Professional Liability coverage for last five years for the firm:
Carrier
Limit
Deductible
Premium
Expiration (Mo/Day/Yr)
If expiring insurance is a claims made policy, what is the retroactive date?
28. Give General Liability coverage for last five years for the firm:
Carrier
Limit
Deductible
Premium
Expiration (Mo/Day/Yr)
If expiring insurance is a claims made policy, what is the retroactive date?
29. Has any application for Professional 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 give details
30. Has any insurer cancelled or refused to renew any similar insurance during the past five years?
Yes
No
If yes, please give details
31. Has any claim ever been made against the firm or any of its employees?
Yes
No
If yes, please 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.
32. Is the applicant aware of any circumstances which may result in any claim against him, the firm, his predecessors in
business, or any of the present or past Partners or Officers?
Yes
No
If yes, please give full details.
Application for Claims-Made Professional Liability Insurance
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 that this Application will be attached and become part of such Policy, if issued.
Underwriters hereby are authorized to make any investigation and inquiry in connection with this Application, as they
deem necessary.

FOR KENTUCKY RISKS: Any person who knowingly and with intent to defraud any insurance company or other
person files an application for insurance containing any materially false information or conceals, for the purpose of
misleading, information concerning any fact material thereto commits a fraudulent act, which is a crime.
Name of Business:
Please Print
Title
Signature: *
Date *
Name *
(NOTE: Application must be signed by the owner or president or principal).
Signature*
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