HEALTHCARE

FACILITY LIABILITY

INSURANCE RENEWAL APPLICATION

THIS POLICY FOR WHICH YOU ARE APPLYING PROVIDES CLAIMS-MADE AND REPORTED COVERAGE. ‘Claims’ or ‘suits’ must first be made against the insured and reported to the company in writing during the policy period unless an extended reporting period applies.

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DO NOT USE THIS APPLICATIONFORHOSPITALS OR LONG-TERM CARE FACILITIES.

I. INSURED’S PROFILE
A. Insured’s Name / B. Policy Number / C. Policy Term
II. PROFESSIONAL LIABILITY EXPOSURES
A. Health Care Services Provided: Check each box that applies and provide projected exposure information for the next 12 months. If you have multiple locations, provide exposure information for each location separately.
Counseling/Rehabilitation: / Visits[1] / Beds[2] / Laboratory: / Receipts[3]
Adolescent/Child Residential Care / Dental Lab / $
Cardiac Rehabilitation / Medical Lab / $
Developmental Disability / Ocular Lab / $
Mental Health/Counseling / Optical Establishment / $
Physical/Occupational Rehabilitation / Organ/Tissue Bank (direct processing) / $
Substance Abuse / Organ/Tissue Bank (no direct processing) / $
Counseling / Pathology Lab / $
Residential / Pharmacy / $
Skilled Medical Services / Quality Control/Reference Lab / $
Trauma Rehabilitation / X-ray/Imaging Center / $
Therapy / Blood/Plasma Banks / Donations[4]
Transitional Living / Other Lab
Skilled Medical Services / Describe:
WeightLossCenter
Other Counseling/Rehabilitation / Treatment: / Visits / Beds
Describe: / College or UniversityHealthCenter
Cancer
Surgical: / CommunityHealthCenter
Abortion Clinic / Crisis Stabilization
Birthing Center / Dialysis
OpticalSurgeryCenter / Health Department
Emergicenter / Med Spa
Surgicenter / Urgicenter
Other Surgical / Other Treatment
Describe: / Describe:
Radiation Therapy / Receipts / $
Telemedicine: Preliminary Reads
Home Care/Hospice: / Telemedicine: Final Reads
Hospice Care
Intravenous Therapy
Personal/Companion Care / Schools for Healthcare Professionals:
Rehabilitation Therapy / Dental
Respiratory Therapy / Medical
Skilled Care / Optometry
Other Home Care/Hospice / Other Healthcare Provider
Describe: / Describe:
Research: (If yes, please attach details of clinical trials.) / Receipts / Services: (Complete Section VI. C – Allied Health Care Professionals and appropriate Supplemental Application.)
Pharmaceuticals / $
Medical Devices / $ / Ground Ambulance Service
Medical/Surgical Procedures / $ / Air Ambulance Service
Medical Registry Services/Medical Personnel Pools
Other Facility:
B. Medical Registry/Staffing Company and Ambulance Company: Provide the expected annual hours worked by your healthcare providers.
City, State / Job Title / Annual Staffing Hours
III. ADDITIONAL EXPOSURES
  1. Have you sold, discontinued or acquired any operations, or do you plan to in the upcoming year?
If yes, please describe in the Comments Section.
  1. Have you added any locations?
If yes, please describe in the Comments Section.
  1. Have you signed any new contracts where you are providing services to others or where others are providing services to you?
If yes, please describe in the Comments Section.
  1. Do you require physicians and contracted allied healthcare professionals to carry professional liability insurance with limits of at least $1,000,000 each occurrence/$3,000,000 aggregate?
If yes, do you require proof of this coverage?
  1. Have you added any new procedures, products, or services?
If yes, please describe in the Comments Section. / YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
Comments Section:
IV. GENERAL LIABILITY ADDITIONAL INTERESTS / Check here if coverage is not applicable -
Check here if there have been no changes in the past year -
Please indicate any additional insureds to be included under your facility’s General Liability Coverage, including an explanation of their interest.
Business Name and Address / Interest
V. UMBRELLA SCHEDULE OF UNDERLYING INSURANCE / Check here if coverage is not applicable -
If you are requesting Umbrella Coverage, please submit an ACORD application.

VI. NOTICE TO APPLICANT

Fraud Prevention - General Warning
NOTICE: Any person who knowingly, or knowingly assists another, files an application for insurance or claim containing any false, incomplete or misleading information for the purpose of defrauding or attempting to defraud an Insurance Company may be guilty of a crime and may be subject to criminal and civil penalties and loss of insurance benefits.
NOTICE TO ARKANSAS, LOUISIANA AND NEW MEXICO APPLICANTS: 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.
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 policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder 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.
NOTICE TO DISTRICT OF COLUMBIA APPLICANTS: Warning, 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.
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 in the third degree.
NOTICE TO KENTUCKY APPLICANTS: Any person who knowingly and with the 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 insurance act, which is a crime.
NOTICE TO MAINE APPLICANTS: It is a crime to 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.
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 NEW YORK APPLICANTS: Any person who knowingly and with intent to defraud any Insurance Company or other person files an application for insurance or statement of claims 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 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.
NOTICE TO OHIO APPLICANTS: Any person who, with intent to defraud or knowing that he 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: 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.
NOTICE TO PENNSYLVANIA APPLICANTS: 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 fact 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.
NOTICE TO TENNESSEEVIRGINIA 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 include imprisonment, fines and denial of insurance benefits.
The undersigned represents that he or she is authorized to sign this application on behalf of the applicant and further represents and acknowledges that all information contained in this application, including any supplements and attachments, is true, accurate and complete; will be relied upon by the company in determining whether to insure the applicant and at what rate to insure it; and will be considered part of any policy that is issued.
The undersigned further represents and acknowledges that the policy applied for provides coverage on a claims made and reported basis and, subject to the policy provisions, will apply only to claims or suits that are first made and reported in writing to the company during the policy period unless an extended reporting period applies.
Applicant Signature: / Producer Signature:
Print Name: / Print Name:
Title: / Date:
Date:

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[1]Visits: Use a threshold count. Count each patient each time they enter your facility for healthcare related services, regardless of the number of departments visited or the number of procedures/treatments performed within each department. For home care, count each patient each time you visit for health related services.

[2]Beds: Use the total number of beds.

[3]Annual Receipts: Use gross receipts. Do not adjust this figure for items such as profit, un-collectible accounts or amounts billed but not paid.

[4]Donations: Use the number of units received from a donor whether paid or not.