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- 1. Human Services Professional Liability General Information Application ACE American Insurance Company Philadelphia, PA 19106 CLAIMS MADE/OCCURRENCE DISCLOSURE NOTICE THE POLICY YOU ARE APPLYING FOR MAY CONTAIN BOTH CLAIMS MADE AND OCCURRENCE COVERAGES. PLEASE READ THE POLICY IN ITS ENTIRETY. SOME OF THE PROVISIONS CONTAINED IN THE POLICY RESTRICT COVERAGE, SPECIFY WHAT IS AND IS NOT COVERED AND DESIGNATE RIGHTS AND DUTIES. Instructions The requested information is necessary before a quotation can be obtained. Type or print clearly. Use for Yes or No answers and other selections. Answer ALL questions completely, leaving no blanks. If any questions, or part thereof, do not apply, print N/A in the appropriate space. Any spaces left blank will be interpreted to not apply. Provide any supporting information on a separate sheet and reference the applicable question number. This application must be completed, dated and signed by an authorized representative of the applicant. Underwriters will rely on all statements made in this application. The information requested in this application is for underwriting purposes only and does not constitute notice to the Company under any Policy of a claim or potential claim. All such notices must be submitted to the Company pursuant to the terms of the Policy, if and when issued. Supporting information: Along with this completed and signed application, the applicant must also submit the following information: Five (5) years of currently valued loss runs For losses exceeding $50,000 and/or loss of life, physical or sexual abuse, please attach a detailed description of said loss/incident. Advise what measures have been taken to prevent similar losses from occurring in the future. Agency descriptive and/or brochures Audited financial Statements Human Services Supplement Abuse Exposure Evaluation Human Services Addiction Treatment and/or Behavioral Healthcare Supplement. I. General Information 1. Applicant/Agency Name (Named Insured as it reads on policy): __________________________________________ _____________________________________________________________________________________________ 2. Federal ID#: ___________________________________________________________________________________ 3. Mailing Address: ________________________________________________________________________________ County: ___________________ City: ____________________ State: _______________ Zip: ____________ 4. Phone: _____________________ Fax: ____________________ Email: ________________________________ 5. Website: _____________________________________________________________________________________ 6. Operating as: Individual Partnership Corporation Other: __________________ 7. Applicant is: For Profit Non-Profit Government Facility Other: _________________ 8. Executive Director: _______________________________ 9. Contact Person for: Human Resource: _______________________________ Loss Control : ___________________________________ Email: _______________________________________ Email: _______________________________________ Email: _______________________________________ 10. Current Operating Budget: _________________________ Years of Operation: _____________________________ 11. Annual Budget for each of the past 2 (two) years: 20____ $_____________________________________ 20____ $_____________________________________ PF-26411b (11/14) Page 1 of 9
- 2. Human Services Professional Liability General Information Application ACE American Insurance Company Philadelphia, PA 19106 12. Primary Funding Source: _________________________________________________________________________ 13. Has Applicant ever filed for protection under Chapter 11 or Chapter 7 of Bankruptcy code (title 11 US Code)? Yes No 14. State Agency(s) in which license(s) are held: _________________________________________________________ _____________________________________________________________________________________________ 15. Expiration dates of current State Licenses: Residential: _______ Day Programs: _______ Others: ________ 16. Are there any Serious Deficiencies noted in most recent Re-Certifications/Compliance Audits? Yes No If yes, please attach list and describe. _______________________________________________________________ _____________________________________________________________________________________________ 17. What state and national Organization(s) or Association(s) is Applicant a member of? __________________________ 18. Is Applicant accredited (e.g. CARF, ACO, JCAHO, etc.) Yes No If yes, what agency/program, level and expiration dates? ________________________________________________ 19. Does Applicant have any Subsidiaries/Holding Corps/Related Organizations with your equity Yes No interest? If yes, please list & describe: ______________________________________________________________ _____________________________________________________________________________________________ 20. Does Applicant have a Pension/Welfare plan? Yes No If yes, please name: _____________________________________________________________________________ 21. Does Applicant act as a Managed Care Organization or Gatekeeper? Yes No 22. List Special Events (i.e. - Special Olympics, Fund Raising, Annual Banquet, etc): _____________________________ _____________________________________________________________________________________________ II. Risk Management 1. Does Applicant have procedures for Incident Reporting? a) Is staff made aware of Incident Reporting Procedures? b) Are program participants instructed on how to report incidents? c) Does Applicant have an active committee that reviews incidents? Yes No Yes No Yes No Yes No 2. Does Applicant have policies & procedures in place for Prescribing/Administering Medication? Yes No 1. Who prescribes/administers medications? ________________________________________________________ 2. Are Non-FDA drugs prescribed or administered? Yes No If yes, please explain: ________________________________________________________________________ __________________________________________________________________________________________ 3. Where and how are drugs stored? ______________________________________________________________ __________________________________________________________________________________________ 3. Does the Applicant have an active Safety Committee? Yes No III. Transportation (If you do not have any owned/leased autos please skip this Section and complete the Non-Owned & Hired Auto Supplement) 1. Does Applicant order Motor Vehicle Records on all drivers? If yes, are they ordered at least Annually? Yes No Yes No 2. Does Applicant order Motor Vehicle Records on new hires, including prospective employees? Yes No 3. Are you enrolled in a state notification system for drivers? Yes No PF-26411b (11/14) Page 2 of 9
- 3. Human Services Professional Liability General Information Application ACE American Insurance Company Philadelphia, PA 19106 4. Does Applicant lend/lease its vehicles to other agencies? Yes No If yes, please describe: __________________________________________________________________________ _____________________________________________________________________________________________ 5. Does Applicant transport anyone other than agency clients? (i.e., Public/School/Seniors) Yes No If yes, please describe: __________________________________________________________________________ _____________________________________________________________________________________________ 6. Do any staff members use their own vehicles on a regular basis for agency business? Yes No If Yes, please indicate how many: __________ If No, please skip to question #10. 7. Do any staff members use their own vehicles to transport clients? Yes No If Yes, please indicate how many: __________ If No, please skip to question #10. 8. Does Applicant require employees to provide certificates of insurance verifying personal automobile coverage? Yes No 9. Does Applicant require employees to carry liability insurance at the state required minimum amount? Yes No 10. Total # of agency owned vehicles: __________ Total # of drivers: __________ a) Does Applicant allow clients under the age of 21 to drive agency vehicles? b) Does Applicant allow employees under the age of 21 to drive agency vehicles? Yes No Yes No If yes to either question, please explain: _____________________________________________________________ _____________________________________________________________________________________________ 11. Does Applicant have drivers over the age of 65? Yes No 12. How many 12/15 Passenger Vans does the Applicant utilize? ______________ 13. For what purpose are the 12/15 Passenger Vans utilized? ______________________________________________ _____________________________________________________________________________________________ 14. If Applicant operates buses, is there a bus maintenance program? If No, Please skip to Section IV. Staffing. If yes, please explain and complete questions a, b, and c below. a) Do drivers hold the appropriate type of licenses? b) Does Applicant have back up drivers that hold the appropriate licenses? Yes No Yes No Yes No c) What type of training is provided to drivers of the buses? Please describe: ______________________________ __________________________________________________________________________________________ IV. Staffing 1. Please indicate total staff: # of Full Time: ________ # of Part Time: ________ Turnover Ratio %: ________ # of Board Members: ________ # of Volunteers: ________ PF-26411b (11/14) Page 3 of 9
- 4. Human Services Professional Liability General Information Application ACE American Insurance Company Philadelphia, PA 19106 2. Annual Payroll: ___________________________________ 3. Exposure count by Classification: Classification Employed Contracted Homemakers, Home Health Nurse Aides, Sitters, Companions, Clerical, Administrative, Bereavement Therapists Full Time _______ Part-Time _______ Full Time _______ Part-Time _______ Dieticians / Nutritionists _______ _______ _______ _______ LPNs, Dental Hygienists, Pharmacy Assistants, Lab Technicians, EKG-Ultrasound Tech, Med Tech, Echocardiogram Tech, X-Ray Technicians, Radiology Technician, Certified Medical Technicians _______ _______ _______ _______ Nurses, Enterstomal Therapists, Social Workers, Dialysis Technicians, Addiction Counselors _______ _______ _______ _______ Occupational Therapists, Speech Pathologists _______ _______ _______ _______ Licensed Mental Health Counselors/Professionals _______ _______ _______ _______ Medical Directors _______ _______ _______ _______ Pharmacists _______ _______ _______ _______ Physical Therapists, Respiratory Therapists, Phlebotomists, Clergy, Nuclear Medicine Technicians, Radiation Therapists _______ _______ _______ _______ Psychologists _______ _______ _______ _______ Nurse Practitioners, Physician Assistants, EMT _______ _______ _______ _______ Psychiatrists _______ _______ _______ _______ Physicians other than Psychiatrists _______ _______ _______ _______ Para-Professional Social Workers / Addiction Interventionists _______ _______ _______ _______ Other: Maintenance, Custodial, Security Worker, Route Drivers _______ _______ _______ _______ 4. Are the Applicants physicians/psychiatrists required to carry Professional Liability insurance? Yes No a) If yes, what are the minimum Professional Liability limits required? $________ _______per occurrence / $_______________aggregate b) Are Applicants physicians/psychiatrists required to provide a certificate of insurance? Yes No 5. Does Applicant employ Attorneys? Yes No PF-26411b (11/14) Page 4 of 9
- 5. Human Services Professional Liability General Information Application ACE American Insurance Company Philadelphia, PA 19106 a) If yes, in what capacity? ________________________________________________________________________ 6. Do the Applicants employed Attorneys carry their own E&O Insurance? Yes No 7. Are there procedures for Pre-Employment Screening? Yes No a) If yes, do they include Reference Checks? Yes No b) Indicate staff In-Services: Safety Behavior Management Patient Rights Medical Administration Other: __________________________________ c) Are staff/volunteers trained in First Aid/CPR? Yes No d) Does the Applicant run criminal background investigations on prospective employees and volunteers? Yes No i. If yes, does the Applicant routinely request and receive such background investigations? Yes No Explain the process: _________________________________________________________________________ __________________________________________________________________________________________ e) Do volunteers follow the same training and screenings as staff? Yes No 8. Does the Applicant verify Employment Related references? Yes No a) If yes, In Person By Telephone 9. Indicate the population served by the Applicants programs (total should equate to 100%). Developmentally Disabled _____% Residential Youth _____% Alcohol/Drug Rehabilitation _____% Boys & Girls Clubs _____% Community Services _____% Big Brothers/Big Sisters _____% Medical/Physical Rehabilitation _____% YWCA _____% Behavioral Healthcare _____% Headstart/Community Action _____% Adoption or Foster Care _____% Other Describe: __________ _____% 10. Has the Applicants policy or coverage been declined, cancelled, or non-renewed during the last three (3) years? (Missouri Policyholders: Do not complete this answer): Yes No a) If yes, describe (Missouri Policyholders: Do not complete this answer): __________________________________ _____________________________________________________________________________________________ 11. Are property values at 100% replacement cost? Yes No 12. If Umbrella coverage is desired over Employers Liability, please provide the following primary coverage details: Carrier: Policy Number: Policy Limits: Effective / Expiration Dates: Premium: Total Annual Payroll $ Each Accident $ Each Policy $ Each Employee $ $ 13. Does the Applicants current insurance program provide Professional Liability Coverage? Yes No a) If yes, provide the limit of liability. $ ___________each occurrence/ $ ___________aggregate 14. Does the Applicants current insurance program provide Abuse/Molestation coverage? Yes No a) If yes, provide the limit of liability. $ ___________each occurrence/ $ ___________aggregate PF-26411b (11/14) Page 5 of 9
- 6. Human Services Professional Liability General Information Application ACE American Insurance Company Philadelphia, PA 19106 15. Does the Applicant have any of the following? Swimming Pool(s) Diving Board(s) Trampoline(s) Horse(s) Ropes Course(s) 16. List Expiring insurance Coverage information (i.e. Professional & General Liability, Property, Auto, Umbrella, D&O): Coverage Type (Professional liability, General Liability, Auto Liability, etc) Company Claims Made or Occurrence Retroactive Date (for claims made coverage only) Expiration Date Deductible Limit of Liability Annual Premium _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ 17. Producer Information: Contact Name__________________________________ Producer Firm: _______________________________ Phone ________________________________________ Email_______________________________________ 18. Where did you hear about the Irwin Siegel Agency? Advertisement Another Insured Association Referral Broker Internet Mailing Telemarketing Call Other___________________________________________________ V. Fraud Warnings and Signatures NOTICE TO ALABAMA APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be subject to restitution fines, or confinement in prison, or any combination thereof. NOTICE TO ARKANSAS, LOUISIANA, RHODE ISLAND & WEST VIRGINIA 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. PF-26411b (11/14) Page 6 of 9
- 7. Human Services Professional Liability General Information Application ACE American Insurance Company Philadelphia, PA 19106 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 of the third degree. NOTICE TO KANSAS APPLICANTS: Any person who, knowingly and with intent to defraud, presents, causes to be presented or prepares with knowledge or belief that it will be presented to or by an insurer, purported insurer, broker or any agent thereof, any written statement as part of, or in support of, an application for the issuance of, or the rating of an insurance policy for personal or commercial insurance, or a claim for payment or other benefit pursuant to an insurance policy for commercial or personal insurance which such person knows to contain materially false information concerning any fact material thereto; or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act. NOTICE TO KENTUCKY APPLICANTS: 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 insurance act, which is a crime. NOTICE TO MAINE 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 or a denial of insurance benefits. NOTICE TO MARYLAND APPLICANTS: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully 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 MINNESOTA APPLICANTS: Any person who knowingly and with intent to defraud any Insurance company or Another person, files an application for insurance containing any materially false information, or conceals information for the purpose of misleading, commits a fraudulent insurance act, which is a crime and MAY subject such person to criminal and civil penalties. 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 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 CIVIL FINES AND CRIMINAL 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 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 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. PF-26411b (11/14) Page 7 of 9
- 8. Human Services Professional Liability General Information Application ACE American Insurance Company Philadelphia, PA 19106 NOTICE TO OREGON APPLICANTS: WARNING: Any person who knowingly and with intent to defraud any insurance company or another 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, may be committing a fraudulent insurance act, which may be a crime and may subject the person to criminal and civil penalties. NOTICE TO PENNSYLVANIA APPLICANTS: 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. NOTICE TO TENNESSEE, VIRGINIA & 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 include imprisonment, fines and denial of insurance benefits. NOTICE TO VERMONT APPLICANTS: Any person who knowingly presents a false statement in an application for insurance may be guilty of a criminal offense and subject to penalties under state law. NOTICE TO ALL OTHER APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR ANOTHER PERSON, FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS INFORMATION FOR THE PURPOSE OF MISLEADING, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND MAY SUBJECT SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES. DECLARATION AND CERTIFICATION BY SIGNING THIS APPLICATION, THE APPLICANT REPRESENTS TO THE COMPANY THAT, TO THE BEST OF THE APPLICANTS KNOWLEDGE, ALL STATEMENTS MADE IN THIS APPLICATION AND ANY SUPPLEMENTS AND ATTACHMENTS HERETO ABOUT THE APPLICANT AND ITS OPERATIONS ARE TRUE AND COMPLETE, AND THAT NO MATERIAL FACTS HAVE BEEN MISSTATED OR MISREPRENSENTED IN THIS APPLICATION OR HAVE BEEN SUPPRESSED OR CONCEALED. THE APPLICANT AGREES THAT IF AFTER THE DATE OF THIS APPLICATION, ANY INCIDENT, OCCURRENCE, EVENT OR OTHER CIRCUMSTANCE SHOULD RENDER ANY OF THE INFORMATION CONTAINED IN THIS APPLICATION OR ANY OTHER DOCUMENTS SUBMITTED IN CONNECTION WITH THE UNDERWRITING OF THIS APPLICATION INACCURATE OR INCOMPLETE, THEN THE APPLICANT SHALL NOTIFY THE COMPANY OF SUCH INCIDENT, OCCURRENCE, EVENT OR CIRCUMSTANCE AND SHALL PROVIDE THE COMPANY WITH INFORMATION THAT WOULD COMPLETE, UPDATE OR CORRECT SUCH INFORMATION. ANY OUTSTANDING QUOTATIONS OR BINDERS MAY BE MODIFIED. COMPLETION OF THIS FORM DOES NOT BIND COVERAGE. THE APPLICANTS ACCEPTANCE OF THE COMPANYS QUOTATION IS REQUIRED BEFORE THE APPLICANT MAY BE BOUND AND A POLICY ISSUED. THE APPLICANT AGREES THAT THIS APPLICATION, IF THE INSURANCE COVERAGE APPLIED FOR IS WRITTEN, SHALL BE THE BASIS OF THE CONTRACT WITH THE INSURANCE COMPANY, AND BE PHYSICALLY ATTACHED THERETO. THE APPLICANT HEREBY AUTHORIZES THE RELEASE OF CLAIMS INFORMATION FROM ANY PRIOR INSURERS TO THE COMPANY. PF-26411b (11/14) Page 8 of 9
- 9. Human Services Professional Liability General Information Application ACE American Insurance Company Philadelphia, PA 19106 THE APPLICANT AGREES TO COOPERATE WITH THE COMPANY IN IMPLEMENTING AN ONGOING PROGRAM OF LOSS-CONTROL AND WILL ALLOW THE COMPANY TO REVIEW AND MONITOR SUCH PROGRAMS THAT THE APPLICANT UNDERTAKES IN MANAGING ITS MEDICAL PROFESSIONAL EXPOSURES. Signature of Applicant Signature of Broker/Agent Title Date Date Signed by Licensed Resident Agent (Where Required By Law) Submit Application to: Irwin Siegel Agency, Inc. PO Box 309 Rock Hill, NY 12775 P: (800) 622-8272 F: (845) 796-3661 www.siegel@siegelagency.com Print Name License Number PF-26411b (11/14) Page 9 of 9
- 10. Human Services Professional Liability General Information Application ACE American Insurance Company Philadelphia, PA 19106 THE APPLICANT AGREES TO COOPERATE WITH THE COMPANY IN IMPLEMENTING AN ONGOING PROGRAM OF LOSS-CONTROL AND WILL ALLOW THE COMPANY TO REVIEW AND MONITOR SUCH PROGRAMS THAT THE APPLICANT UNDERTAKES IN MANAGING ITS MEDICAL PROFESSIONAL EXPOSURES. Signature of Applicant Signature of Broker/Agent Title Date Date Signed by Licensed Resident Agent (Where Required By Law) Submit Application to: Irwin Siegel Agency, Inc. PO Box 309 Rock Hill, NY 12775 P: (800) 622-8272 F: (845) 796-3661 www.siegel@siegelagency.com Print Name License Number PF-26411b (11/14) Page 9 of 9