Home Healthcare

  • (If multiple name and locations, please attach list)
  • 11. Does the applicant have any ancillary operations not stated above?

  • 13. a) List the number and type of applicant's employees estimated over the next 12 months. If none, state none.
  • 13. b) List the number and type of independent contractors estimated over the next 12 months. If none, state none.

  • c) Are all the above individuals licensed in accordance with applicable state and federal regulations

  • 14. Do you require contracted staff (if any) to carry their own Professional Liability Insurance & secure certificates of Insurance as evidence of such coverage?

  • If no, is coverage desired with shared limits on this policy?

  • 15. a) Enter where services are provided, broken down by percentage for each category, by employees & independent contractors:

  • 15. b) State approximate division of applicant's patients among:

  • 16. For Medical Personnel Staffing Agencies, enter which departments/areas are staffed broken down by percentage (please estimate if this is a start-up):

  • 17. a) Enter the percentages for the following exposures based on total services provided (please estimate if this is a start- up):

  • 17. b) Does the applicant perform:

  • a. Surgery other than an incision of superficial boils or suturing superficial fascia?

  • b. Circumcisions and/or dilation and curettage and/or insertion of temporary pacemakers?

  • c. Obstetric procedures?

  • d. Cosmetic plastic surgery?

  • e. Excision of large cysts and/or I&D of deep-seated boils or carbuncles?

  • f. Hysterectomies?

  • g. Open reduction of fractures?

  • h. Surgery for weight reduction of patients?

  • i. Silicone implants?

  • j. Sterilization procedures?

  • k. Biopsies and/or endoscopies?

  • l. Sex Change operations?

  • m. Other surgery?

  • 17. c) Does the applicant perform hospital emergency room care:

  • a. for its own regular patients?

  • b. for patients not own?

  • c. if answer to b. is Yes, please specify

  • 17. d) Does the applicant use drugs for weight reduction of patients?

  • 17. e) Does the applicant administer any methadone treatment?

  • 17. f) Is anesthesia (other than topical or by means of local infiltration) administered by either applicant or others?

  • 21. Are patients accepted for health care services only upon a written plan of treatment established by an attending physician?
  • 22. a) Do you conduct pre-employment screening and investigation?

  • b) Do you question prospects about previous claims or suits?

  • c) Are employees required to actively participate in continuing education?

  • d) Do you prepare job descriptions and instructional manuals for your staff?

  • e) Do you have a written incident/occurrence reporting policy and procedures?

  • 23. Check all the following that apply if obtained, verified & kept on file as part of the employee hiring & screening process:

  • a) Ever been the subject of disciplinary or investigative proceedings or reprimand by a governmental or administrative agency, hospital or professional association?

  • b) Ever been convicted for an act committed in violation of any law or ordinance other than traffic offenses?

  • c) Ever been treated for alcoholism or drug addiction?

  • 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?

  • 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?

  • 27. Give Professional Liability coverage for last five years for the firm:

  • 28. Give General Liability coverage for last five years for the firm:

  • 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?

  • 31. Has any claim ever been made against the firm or any of its employees?

  • 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?

  • 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.

  • Please Print
  • Title
  • Signature: *

  • Date *
  • Name *
  • (NOTE: Application must be signed by the owner or president or principal).

  • This field is for validation purposes and should be left unchanged.