HPL-656 (05-14) Hospital Application.docx



AXIS HEALTHCARE PROFESSIONAL LIABILITYINSURANCE POLICYlefttop00HOSPITAL APPLICATION(for surplus lines coverage)AXIS SURPLUS INSURANCE COMPANYProducerAgency Name: FORMTEXT ?????Producer Name: FORMTEXT ?????Telephone: FORMTEXT ?????E-Mail: FORMTEXT ?????ApplicantNamed Insured: FORMTEXT ?????County: FORMTEXT ?????Address: FORMTEXT ?????City/State/Zip: FORMTEXT ?????CEO: FORMTEXT ?????Risk Manager: FORMTEXT ?????Website: FORMTEXT ?????Authorized representative for insurance matters: FORMTEXT ?????Telephone: FORMTEXT ?????Number of years the Applicant has been in operation: FORMTEXT ?????Number of years the Applicant has been under present ownership: FORMTEXT ?????Other EntitiesList all owned (50% or more) entities to be considered as a Named Insured, or attach a separate list:NameType/Purpose of FacilityRetroactive Date FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Facility InformationType (check all that apply)Ownership and ControlTax Status FORMCHECKBOX Children’s Hospital FORMCHECKBOX Governmental FORMCHECKBOX For Profit FORMCHECKBOX Clinic FORMCHECKBOX Individual FORMCHECKBOX Not for Profit FORMCHECKBOX Convalescent or Nursing Home FORMCHECKBOX Partnership FORMCHECKBOX Medicare Approved FORMCHECKBOX General Acute Care Hospital FORMCHECKBOX Corporation FORMCHECKBOX Hospice FORMCHECKBOX Psychiatric Hospital FORMCHECKBOX Research Hospital FORMCHECKBOX Surgical Center FORMCHECKBOX Teaching HospitalThe facility is (check all that apply): FORMCHECKBOX Accredited by AOA* FORMCHECKBOX Member of American Hospital Association FORMCHECKBOX Medicare Approved FORMCHECKBOX Accredited by JCAHO* FORMCHECKBOX Member of State Hospital Association FORMCHECKBOX Other (describe below): FORMTEXT ?????*Date of last survey: FORMTEXT ????? *Accreditation Period: FORMTEXT ?????Details of Requested CoverageRequested Effective Date: FORMTEXT ?????Expiration Date: FORMTEXT ?????Date Quote is Needed: FORMTEXT ?????Requested Limits FORMCHECKBOX Professional Liability$ FORMTEXT ?????per claim$ FORMTEXT ?????aggregateClaims Made Retroactive Date: FORMTEXT ????? FORMCHECKBOX General Liability$ FORMTEXT ?????per claim$ FORMTEXT ?????aggregate FORMCHECKBOX Occurrence Coverage FORMCHECKBOX Claims Made Retroactive Date: FORMTEXT ????? FORMCHECKBOX Employee Benefits Admin. Liability (EBL)$ FORMTEXT ?????per claim$ FORMTEXT ?????aggregateClaims Made Retroactive Date: FORMTEXT ?????Total number of employees: FORMTEXT ????? FORMCHECKBOX Excess Liability$ FORMTEXT ?????per claim$ FORMTEXT ?????aggregateClaims Made Retroactive Date: FORMTEXT ????? FORMCHECKBOX Umbrella Liability$ FORMTEXT ?????per claim$ FORMTEXT ?????aggregateClaims Made Retroactive Date: FORMTEXT ?????Deductible FORMCHECKBOX NoneApplies to: FORMCHECKBOX Professional Liability$ FORMTEXT ?????per claim$ FORMTEXT ?????aggregate FORMCHECKBOX Indemnity Only or FORMCHECKBOX Indemnity & Expense FORMCHECKBOX General Liability$ FORMTEXT ?????per claim$ FORMTEXT ?????aggregate FORMCHECKBOX Indemnity Only or FORMCHECKBOX Indemnity & Expense FORMCHECKBOX Employee Benefits Admin. Liability (EBL)$ FORMTEXT ?????per claim$ FORMTEXT ?????aggregate FORMCHECKBOX Indemnity Only or FORMCHECKBOX Indemnity & ExpenseSelf-Insured Retention FORMCHECKBOX NoneApplies to: FORMCHECKBOX Professional Liability$ FORMTEXT ?????per claim$ FORMTEXT ?????aggregate FORMCHECKBOX Indemnity Only or FORMCHECKBOX Indemnity & ExpenseSIR applies to: FORMCHECKBOX Professional FORMCHECKBOX General FORMCHECKBOX EBL FORMCHECKBOX Other: FORMTEXT ?????Is there an Insurance Trust? FORMCHECKBOX Yes FORMCHECKBOX NoIs there an Insurance Captive? FORMCHECKBOX Yes FORMCHECKBOX NoWho currently handles claims within the SIR? FORMTEXT ?????Prior Insurance HistoryComplete the following professional liability insurance history:Current carrier*: FORMTEXT ?????*attach copy of current policy FORMCHECKBOX Claims Made FORMCHECKBOX OccurrenceEffective Date: FORMTEXT ????? Expiration Date: FORMTEXT ?????Retroactive Date: FORMTEXT ?????Limits: $ FORMTEXT ????? / $ FORMTEXT ????? FORMCHECKBOX Deductible/SIR $ FORMTEXT ?????Expiring premium: $ FORMTEXT ?????1st prior carrier : FORMTEXT ????? FORMCHECKBOX Claims Made FORMCHECKBOX OccurrenceEffective Date: FORMTEXT ?????Expiration Date: FORMTEXT ?????Retroactive Date: FORMTEXT ?????2nd prior carrier : FORMTEXT ????? FORMCHECKBOX Claims Made FORMCHECKBOX OccurrenceEffective Date: FORMTEXT ?????Expiration Date: FORMTEXT ?????Retroactive Date: FORMTEXT ?????If you are currently insured on a claims-made policy, are you obtaining Extended Reporting Period (“Tail”) Coverage from your current insurance carrier? FORMCHECKBOX Yes FORMCHECKBOX NoNote: To prevent possible gaps in your Claims-Made coverage, either Extended Reporting Period Coverage from your current insurer or Prior Acts Coverage from AXIS must be purchased. Prior Acts Coverage is subject to underwriting approval and may not be available to all applicants.Census DataBEDSOccupancy: The daily average number of occupied beds shall be the sum of the annual occupancy divided by 365. Acute Care Beds are defined as: All beds licensed by the state, including but not limited to, all beds designated for burn, coronary, intensive care, medical, surgical, pediatrics, or other acute care patients.Number of Licensed BedsAverage Annual Occupied BedsCurrent Year1st Prior2nd PriorCurrent Year1st Prior2nd PriorAcute Care FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Cribs & Bassinets FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Psychiatric FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Rehabilitation FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Swing Beds FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????NURSING HOME BEDS FORMCHECKBOX N/A (applicant has no nursing home beds)Skilled Care FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Intermediate Care FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Residential Care FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Independent Living FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Visits & ProceduresCurrent annual visitsProjected annual visitsEmergency Medicine FORMTEXT ????? FORMTEXT ?????Mental Health FORMTEXT ????? FORMTEXT ?????Alcohol/Drug Rehabilitation FORMTEXT ????? FORMTEXT ?????Physical Rehabilitation/Therapy FORMTEXT ????? FORMTEXT ?????Home Health Care FORMTEXT ????? FORMTEXT ?????Nursing Home Visits FORMTEXT ????? FORMTEXT ?????Other Outpatient Visits (excluding Bariatric) FORMTEXT ????? FORMTEXT ?????Inpatient Surgeries (excluding Bariatric) FORMTEXT ????? FORMTEXT ?????Outpatient Surgeries FORMTEXT ????? FORMTEXT ?????Bariatric Surgeries (Outpatient/Inpatient) FORMTEXT ????? / FORMTEXT ????? FORMTEXT ????? / FORMTEXT ?????Total Deliveries (including C-sections) FORMTEXT ????? FORMTEXT ?????Cesarean Sections (C-sections) FORMTEXT ????? FORMTEXT ?????Vaginal Births after C-Section (VBACs) FORMTEXT ????? FORMTEXT ?????Other exposures (specify): FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????PersonnelList the number of each provider type:NOTE: No individual coverage is afforded to specialties marked with an “*” unless specifically requested.Provider TypeEmployeesIndependent ContractorsHave Separate Coverage*Employed Physician FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No*Employed Resident FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX NoNurse Anesthetist FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX NoNurse Midwife FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX NoNurse Practitioner FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX NoPhysician Assistant FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX NoPodiatrist FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX NoPsychologist FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX NoDentist FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No*If coverage is requested, individual applications may be required.Services FORMCHECKBOX None of theseIndicate if the Applicant presently provides or operates, or plans to provide or operate any of the following: FORMCHECKBOX Abortion Clinic FORMCHECKBOX Dental Services FORMCHECKBOX Intensive Care Unit FORMCHECKBOX Pediatrics FORMCHECKBOX Ambulance Service * FORMCHECKBOX Dialysis FORMCHECKBOX Long-Term Care FORMCHECKBOX Rehabilitation FORMCHECKBOX Bariatric Surgery ? FORMCHECKBOX Emergency Room FORMCHECKBOX Neonatal ICU FORMCHECKBOX Research/Experimental Surg. FORMCHECKBOX Birthing Suites FORMCHECKBOX Fitness Center * FORMCHECKBOX Nursery FORMCHECKBOX Robotic Surgery FORMCHECKBOX Blood Bank * FORMCHECKBOX General Medicine FORMCHECKBOX OB / GYN FORMCHECKBOX Skilled Nursing FORMCHECKBOX Cardiac Cath. Center FORMCHECKBOX General Surgery FORMCHECKBOX Oncology FORMCHECKBOX Teleradiology ? FORMCHECKBOX Chemical Dependency FORMCHECKBOX Geriatrics FORMCHECKBOX Organ Transplants FORMCHECKBOX Telemedicine (non radiology) FORMCHECKBOX Concierge Medicine FORMCHECKBOX HMO FORMCHECKBOX Outpatient Surg. FORMCHECKBOX Transplants FORMCHECKBOX Coronary Care Unit FORMCHECKBOX Home Health FORMCHECKBOX Pain Management FORMCHECKBOX Transportation Services FORMCHECKBOX Day Care * FORMCHECKBOX Hospice FORMCHECKBOX Pathology FORMCHECKBOX Trauma Centers FORMCHECKBOX Other (describe): FORMTEXT ?????? Supplemental application is required.*Complete the following information for SERVICES selected above:Ambulance ServiceFitness Center# of runs per year: FORMTEXT ?????# of vehicles: FORMTEXT ????? FORMCHECKBOX On premises FORMCHECKBOX General publicEmployed EMTs/Paramedics? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Patient only FORMCHECKBOX Swimming poolIf “Yes,” how many? FORMTEXT ?????Blood BankDay CareAre you accredited by: FORMCHECKBOX AABB FORMCHECKBOX CAPKids per day: FORMTEXT ?????Caregiver/Child Ratio: FORMTEXT ????? FORMCHECKBOX Hospital patients only FORMCHECKBOX Used by outside patientsEmergency DepartmentWhat is the JCAHO designation of the Emergency Department? FORMCHECKBOX N/A FORMCHECKBOX Level I (tertiary) FORMCHECKBOX Level II (comprehensive) FORMCHECKBOX Level III (basic) FORMCHECKBOX Level IV (standby) FORMCHECKBOX Level VEmergency Department is staffed by (check all that apply): FORMCHECKBOX Employed Physicians FORMCHECKBOX Contract Group FORMCHECKBOX Staff PhysiciansIf under contract, provide name of group: FORMTEXT ?????Required Professional Liability limits: $ FORMTEXT ????? / $ FORMTEXT ?????Are all ER physicians required to be Board Certified or eligible in Emergency Medicine? FORMCHECKBOX Yes FORMCHECKBOX NoAre the ER physicians required to respond to cardiac/respiratory arrests or other medical Emergencies occurring in the institution? FORMCHECKBOX Yes FORMCHECKBOX NoIs the Emergency Room equipped with the following:Emergency resuscitation care equipped with defibrillator FORMCHECKBOX Yes FORMCHECKBOX NoElectrocardiograph machine FORMCHECKBOX Yes FORMCHECKBOX NoStaffed radiology room(s) FORMCHECKBOX Yes FORMCHECKBOX NoDedicated triage area and staff FORMCHECKBOX Yes FORMCHECKBOX NoDedicated trauma room(s) and staff FORMCHECKBOX Yes FORMCHECKBOX NoDedicated laboratory personnel FORMCHECKBOX Yes FORMCHECKBOX NoDo any of the Emergency Department staff routinely work more than a eight (8) hour duty shift? If “Yes,” explain: FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX NoSurgeryAre any of the following performed at your facility and/or outpatient surgicenters? FORMCHECKBOX NoneProcedureHospitalOutpatient CenterNot PerformedAnnual # DoneCosmetic Surgery FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Experimental Surgery FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Laser-Assisted Surgery / LASIK Surgery FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Neurosurgery FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Sex Change / Gender Reassignment Surgery FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Weight Reduction / Bariatric Surgery FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????PathologyPathology Department is staffed by (check all that apply): FORMCHECKBOX Employed Physicians FORMCHECKBOX Contract Group FORMCHECKBOX Staff PhysiciansIf under contract, provide name of group: FORMTEXT ?????Required Professional Liability limits: $ FORMTEXT ????? / $ FORMTEXT ?????AnesthesiaAnesthesiology Department is staffed by (check all that apply): FORMCHECKBOX Employed Physicians FORMCHECKBOX Contract Group FORMCHECKBOX Staff PhysiciansIf under contract, provide name of group: FORMTEXT ?????Required Professional Liability limits: $ FORMTEXT ????? / $ FORMTEXT ?????Are all anesthesiologists required to be Board Certified or eligible in Anesthesiology? FORMCHECKBOX Yes FORMCHECKBOX NoDo CRNA’s provide anesthesia services? FORMCHECKBOX Yes FORMCHECKBOX NoCRNA employment by: FORMCHECKBOX Applicant FORMCHECKBOX Anesthesiology FORMCHECKBOX Surgeon FORMCHECKBOX Independent ContractorIs the anesthesia care performed by CRNA’s supervised and reviewed by the anesthesiologists? If “No,” explain: FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX NoRadiologyRadiology Department is staffed by (check all that apply): FORMCHECKBOX Employed Physicians FORMCHECKBOX Contract Group FORMCHECKBOX Staff PhysiciansIf under contract, provide name of group: FORMTEXT ?????Required Professional Liability limits: $ FORMTEXT ????? / $ FORMTEXT ?????Are all radiologists required to be Board Certified in Radiology or Nuclear Medicine? FORMCHECKBOX Yes FORMCHECKBOX NoState the number of X-ray machines owned and/or operated: FORMTEXT ?????How many are used for:Diagnosis: FORMTEXT ?????Treatment: FORMTEXT ?????Both: FORMTEXT ?????ObstetricsHow many of each do you have?Labor rooms FORMTEXT ?????Delivery rooms FORMTEXT ?????Birthing suites FORMTEXT ?????Is the delivery room suite separate from the surgical suite? FORMCHECKBOX Yes FORMCHECKBOX NoWhat is the C-section rate for the previous 12-month period ? FORMTEXT ?????Are you in current compliance with all ACOG standards, including those that pertain to C-sections? FORMCHECKBOX Yes FORMCHECKBOX NoIs an Obstetrician available in-house twenty-four (24) hours per day for the obstetrics suite? If “No,” what is the maximum time allowed for arrival at the facility? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX NoIs an Anesthesiologist or CRNA available in-house twenty-four (24) hours per day? If “No,” what is the maximum time for arrival at the facility? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX NoIf the Applicant has a neonatal intensive care unit (NICU), what is the total number of neonates admitted in the last 12 months? FORMTEXT ????? FORMCHECKBOX N/A (we do not have a NICU)Is the Applicant a regional referral center for newborns requiring intensive care? If “Yes,” how many were transferred from other facilities? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX NoIs a full-time attending neonatologist on-site in the NICU twenty-four (24) hours per day? FORMCHECKBOX Yes FORMCHECKBOX NoDo providers other than Obstetricians (Family Practice with OB, CNMs, etc.) ever deliver babies in your hospital? If “Yes,” explain: FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX NoStaff Credentialing & PrivilegesAre credentials for all Physicians and Allied Professionals checked and approved prior to granting staff privileges? FORMCHECKBOX Yes FORMCHECKBOX NoAre privileges probationary? What is the amount of probationary time? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX NoAre new staff members proctored? FORMCHECKBOX Yes FORMCHECKBOX NoAre there any Physicians or Allied Professionals who are not licensed or who have restricted licenses or privileges? FORMCHECKBOX Yes FORMCHECKBOX NoAre Physicians and Allied Professionals privileges reviewed at least once every other year? FORMCHECKBOX Yes FORMCHECKBOX NoAre all foreign medical graduates certified by the Educational Council for Foreign Medical Graduates (ECFMG) or have they passed the FLEX? FORMCHECKBOX Yes FORMCHECKBOX NoAre independent Physicians and Allied Professionals required to maintain professional liability insurance? What are the required limits? $ FORMTEXT ????? / $ FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX NoAre certificates of insurance required as verification of insurance? FORMCHECKBOX Yes FORMCHECKBOX NoRisk ManagementIs there an individual who is designated with the job title and role of Risk Manager? If “No,” explain: FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX NoIs there a written, formalized Risk Management plan? If “No,” explain: FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX NoIs this plan regularly reviewed for effectiveness and/or any necessary changes? If “Yes,” how often is the plan reviewed? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX NoIs there an ongoing Quality Assessment or Improvement plan? If “No,” explain: FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX NoContractual AgreementsIdentify any remaining contracted professional services performed at the hospital not previously identified FORMCHECKBOX None (all have been previously identified) FORMCHECKBOX Home Health FORMCHECKBOX Occupational Therapy FORMCHECKBOX Physical Therapy FORMCHECKBOX Laboratory FORMCHECKBOX Pharmacy FORMCHECKBOX Respiratory Therapy FORMCHECKBOX Other: FORMTEXT ?????Does the applicant require contractors to provide verification of professional liability insurance? If “Yes,” what limits are required? $ FORMTEXT ????? / $ FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX NoAre all contracts reviewed by legal counsel prior to execution? FORMCHECKBOX Yes FORMCHECKBOX NoDoes the applicant indemnify (hold harmless) any other party for liability? If “Yes,” submit a copy of the agreement with this application. FORMCHECKBOX Yes FORMCHECKBOX NoDoes the applicant rent or lease equipment to or from others? FORMCHECKBOX Yes FORMCHECKBOX NoDoes the applicant contract outside entities for the removal and/or disposal of any of the following wastes? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Low Level Radioactive FORMCHECKBOX Hazardous or Toxic FORMCHECKBOX Other Radioactive FORMCHECKBOX Medical or InfectiousIf “Yes” to any of the above, is evidence of insurance required? What are the minimum limits required? $ FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX NoDoes the applicant have any on-site dumps, landfills, or other disposal areas? FORMCHECKBOX Yes FORMCHECKBOX NoGeneral InformationDoes the applicant engage in any of the following:a.Formal clinical research under the auspices of an institutional review board? FORMCHECKBOX Yes FORMCHECKBOX Nob.Administration of non-FDA approved pharmaceuticals (experimental drugs)? FORMCHECKBOX Yes FORMCHECKBOX Noc.Biomedical device research and development? FORMCHECKBOX Yes FORMCHECKBOX Nod.Animal research? FORMCHECKBOX Yes FORMCHECKBOX Noe.Medical and/or surgical experimentation that is not approved by an IRB? FORMCHECKBOX Yes FORMCHECKBOX NoIf “Yes” to any of the above, provide details: FORMTEXT ?????Has the Applicant or other associated entity ever had its license revoked, suspended or placed on probation by any licensing agency? If “Yes,” explain: FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX NoHas the Applicant ever been investigated by any third party for alleged fraud, erroneous billing or entered into a Compliance Integrity Agreement? If “Yes,” explain: FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX NoHas the Applicant entered into any joint ventures or limited partnerships? If “Yes,” explain: (name of venture, % of ownership & description) FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX NoIs any part of the Applicant operated/leased by a management corporation? If “Yes,” give the name of the corporation, details of the structure and provide a copy of the contract: FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX NoDoes the Applicant participate in any teaching programs or have affiliations with educational institutions? If “Yes,” explain: FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX NoDoes the Applicant anticipate any facility or service expansions within the next year? If “Yes,” explain: FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX NoDoes the Applicant anticipate any sale of assets, mergers, acquisitions, consolidation or change in operations or services within the next twelve (12) months? If “Yes,” explain: FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX NoProvide a detailed explanation for the following questions answered “Yes”, on a separate sheet of paper:Has any company ever declined, cancelled, refused to renew, restricted, or surcharged your professional liability insurance? FORMCHECKBOX Yes FORMCHECKBOX NoHave there been any complaints or suits brought against the applicant by a member of its medical staff or any other provider working in the facility? FORMCHECKBOX Yes FORMCHECKBOX NoIs the applicant aware of any conduct, circumstance, occurrence, incident, or accident that is likely to or reasonably could be expected to give rise to a claim that has not yet been reported to the current and/or prior insurance carrier? FORMCHECKBOX Yes FORMCHECKBOX NoPhysical PremisesList all buildings the applicant owns, controls, or occupies or attach a separate list.AddressUseConstruction(Brick, Fire Resistive etc.)Year Built# Of StoriesTotal Sq. plete Sprinkler System FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX NoDoes the Applicant own, rent, or charter any aircraft or helicopters? FORMCHECKBOX Yes FORMCHECKBOX NoDoes the Applicant have or maintain a heliport/helipad? FORMCHECKBOX Yes FORMCHECKBOX Noa.If “Yes,” where is the pad located (e.g., parking lot, top of building etc.) FORMTEXT ?????b.Is the area identified with warning signs and/or fencing? FORMCHECKBOX Yes FORMCHECKBOX Noc.Is the area equipped with proper lighting for night or foul weather landings? FORMCHECKBOX Yes FORMCHECKBOX Nod.How many annual landings do you have? FORMTEXT ?????Does the Applicant own ambulances or other emergency vehicles? FORMCHECKBOX Yes FORMCHECKBOX NoDo all locations meet applicable National Fire Protection Agency (NFPA) building codes? FORMCHECKBOX Yes FORMCHECKBOX NoAutomobile ExposuresIf the applicant owns, controls, or hires any automobiles, attach a copy of your business auto coverage if you desire excess or umbrella coverage from AXIS for this exposure and complete the following:Type of ownership# of Private Passenger Autos# of Multi-Passenger Autos# of AmbulancesOwned FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Non-owned or hired FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????THE UNDERSIGNED AUTHORIZED OFFICER OF THE APPLICANT DECLARES THAT THE STATEMENTS SET FORTH HEREIN ARE TRUE, AND AFFIRMS THAT IF THE INFORMATION SUPPLIED IN THIS APPLICATION CHANGES BETWEEN THE DATE OF THIS APPLICATION AND THE EFFECTIVE DATE OF INSURANCE, THE UNDERSIGNED WILL IMMEDIATELY NOTIFY THE INSURER OF SUCH CHANGES, AND THE INSURER MAY WITHDRAW OR MODIFY ANY OUTSTANDING QUOTATIONS OR AUTHORIZATIONS OR AGREEMENT TO BIND INSURANCE. FURTHERMORE, THE UNDERSIGNED DECLARES THAT THE SIGNING OF THIS FORM DOES NOT BIND COVERAGE NOR COMMIT TO ORDERING COVERAGE. Alabama Fraud Statement“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.”Arkansas, Louisiana, Rhode Island, and West Virginia Fraud Statement“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.”Colorado Fraud Statement“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.”District of Columbia Fraud Statement“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.”Florida Fraud Statement“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.”Kentucky Fraud Statement“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.”Maine Fraud Statement“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.”Maryland Fraud Statement"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."New Jersey Fraud Statement“Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties.”New Mexico Fraud Statement“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.”Ohio Fraud Statement“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.”Oklahoma Fraud Statement“WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.”Oregon Fraud StatementAny person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents materially false information in an application for insurance may be guilty of a crime and may be subject to fines and confinement in prison.In order for us to deny a claim on the basis of misstatements, misrepresentations, omissions or concealments on your part, we must show that:A. The misinformation is material to the content of the policy;B. We relied upon the misinformation; andC. The information was either:1. Material to the risk assumed by us; or2. Provided fraudulently.For remedies other than the denial of a claim, misstatements, misrepresentations, omissions or concealments on your part must either be fraudulent or material to our interests.With regard to fire insurance, in order to trigger the right to remedy, material misrepresentations must be willful or intentional.Misstatements, misrepresentations, omissions or concealments on your part are not fraudulent unless they are made with the intent to knowingly defraud.Pennsylvania Fraud Statement“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.”Tennessee, Virginia and Washington Fraud Statement“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.”This application is for insurance to be placed on a surplus lines basis with AXIS Surplus Insurance Company. FORMTEXT ????? FORMTEXT ?????Applicant’s SignaturePrint Name & Title(must be signed by the President, CEO, Chairman, Executive Director, CFO, COO or Risk Manager)DateAttach copies of the following with this application: FORMCHECKBOX Current Audited Financial Statement FORMCHECKBOX Risk Management Plan FORMCHECKBOX Current Professional Liability Policy FORMCHECKBOX Medical Staff Bylaws FORMCHECKBOX Current Loss Run(s) (valued within 60 days for the current year and a minimum of 5 additional years) FORMCHECKBOX Agreements where other parties are indemnified FORMCHECKBOX JCAHO or other Accreditation survey (JCAHO - Submit a copy of the most recent JCAHO Accreditation Letter, Scoring Grid and Type 1 Recommendations and responses) FORMCHECKBOX Business auto declarations page and loss runs (if excess/umbrella auto coverage desired)Supplemental Claim Information FormA copy of this completed and signed supplement is required for all claims involving the applicant. Copies should be made as needed.Claim BasicsApplicant Name: FORMTEXT ?????Claimant Information:Initials: FORMTEXT ?????Age: FORMTEXT ?????Gender: FORMCHECKBOX M FORMCHECKBOX FDate of Alleged Incident: FORMTEXT ?????Date Claims was Made: FORMTEXT ?????Additional Defendant(s): FORMCHECKBOX NoneList: FORMTEXT ?????Insurer to Whom Claim was Reported: FORMTEXT ?????Claim Status FORMCHECKBOX Dismissed with Prejudice FORMCHECKBOX Dismissed without Prejudice FORMCHECKBOX Defense Verdict FORMCHECKBOX Plaintiff VerdictTotal Award: $ FORMTEXT ?????Amount Paid on Your Behalf: $ FORMTEXT ????? FORMCHECKBOX SettlementTotal Award: $ FORMTEXT ?????Amount Paid on Your Behalf: $ FORMTEXT ????? FORMCHECKBOX OpenAmount of Reserve: $ FORMTEXT ?????Amount of Plaintiff’s Demand: $ FORMTEXT ?????Claim DescriptionAlleged act(s) on which the claim was based: FORMTEXT ?????Description of the Claim: FORMTEXT ?????Injury or Damage alleged to have been caused: FORMTEXT ?????Other information (optional): FORMTEXT ?????I attest that the above information is true and complete to the best of my knowledge, that this information becomes a part of my application for coverage to AXIS, and that it is subject to the same conditions and warranty of my AXIS application. FORMTEXT ????? FORMTEXT ?????Applicant’s SignaturePrint Name & Title(must be signed by the President, CEO, Chairman, Executive Director, CFO, COO or Risk Manager)DateNursing Home SupplementApplicant FORMCHECKBOX Check this box to confirm all is the same here as it is for the hospitalNamed Insured: FORMTEXT ?????County: FORMTEXT ?????Address: FORMTEXT ?????City/State/Zip: FORMTEXT ?????CEO: FORMTEXT ?????Risk Manager: FORMTEXT ?????Website: FORMTEXT ?????Authorized representative for insurance matters: FORMTEXT ?????Telephone: FORMTEXT ?????Facility HistoryHow long has the facility been in operation under your control? FORMTEXT ????? years FORMTEXT ????? monthsIs the facility certified for Medicaid reimbursement? If “No,” explain: FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX NoHas the facility’s license ever been revoked? If “Yes,” explain: FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX NoFacility TypeOwnership FORMCHECKBOX Skilled Nursing Facility (24-hour nursing care services are provided) FORMCHECKBOX Corporate Ownership (100%) (list name of corporate owner): FORMTEXT ????? FORMCHECKBOX Intermediate Care Facility (medical, nursing, social & rehabilitative services are provided) FORMCHECKBOX Joint Venture / Partnership (list all parties with their % of ownership): FORMTEXT ????? FORMCHECKBOX Personal Care Facility (non-continuous nursing care with supervised living care) FORMCHECKBOX Individually owned (list name of individual owner): FORMTEXT ????? FORMCHECKBOX Other (describe): FORMTEXT ????? FORMCHECKBOX Other (describe): FORMTEXT ?????Facility ServicesAre all bedridden patients on the ground floor? If “No,” explain: FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX NoAre any of the following services contracted from outside the facility? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Dental FORMCHECKBOX Dialysis FORMCHECKBOX Grooming/Beauty FORMCHECKBOX Inhalation Therapy FORMCHECKBOX Physical Therapy FORMCHECKBOX X-Ray FORMCHECKBOX Other (describe): FORMTEXT ?????Are Certificates of Insurance required from all contractors for outside services? FORMCHECKBOX Yes FORMCHECKBOX NoIf “Yes,” what limits of insurance are required? $ FORMTEXT ?????Does the nursing home own or operate any of the following services? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Home Health Care Services FORMCHECKBOX Durable medical Equipment Service FORMCHECKBOX Adult Day Care FORMCHECKBOX Wellness / Fitness Center Program FORMCHECKBOX Pharmacy for patients only FORMCHECKBOX Pharmacy for non-patientsDoes the facility sponsor any recreational events involving residents and outsiders? FORMCHECKBOX Yes FORMCHECKBOX NoIf “Yes,” describe: FORMTEXT ?????What is your ratio of patients to nurses? FORMTEXT ????? patients to FORMTEXT ????? nursesHow many of each of the following employees do you have (if none, show 0)? FORMTEXT ????? LPNs FORMTEXT ????? RNs FORMTEXT ????? Nurse Aides FORMTEXT ????? Therapists FORMTEXT ????? Pharmacist FORMTEXT ????? Volunteers FORMTEXT ????? Other (describe): FORMTEXT ?????Do you have a transportation arrangement in place for patients requiring acute care?If “Yes,” list the facility name and # of miles from your facility: FORMTEXT ????? Is a physician appointed to act as the Medical Director of the facility FORMCHECKBOX Yes FORMCHECKBOX NoDo you credential all attending physicians treating patients in your facility? FORMCHECKBOX Yes FORMCHECKBOX NoI attest that the above information is true and complete to the best of my knowledge, that this information becomes a part of my application for coverage to AXIS, and that it is subject to the same conditions and warranty of my AXIS application. FORMTEXT ????? FORMTEXT ?????Applicant’s SignaturePrint Name & Title(must be signed by the President, CEO, Chairman, Executive Director, CFO, COO or Risk Manager)DateAXIS Surplus Insurance CompanyProfessional Employee Roster(make copies of this page as needed)Last NameFirst NamePT?*SpecialtyNPI#**Retroactive Date1. FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????2. FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????3. FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????4. FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????5. FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????6. FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????7. FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????8. FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????9. FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????10. FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????11. FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????12. FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????13. FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????14. FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????15. FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????16. FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????17. FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????18. FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????19. FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????20. FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????21. FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????22. FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????23. FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????24. FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????25. FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????26. FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????27. FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????28. FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????29. FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????30. FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????31. FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????32. FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????33. FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????34. FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????35. FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????36. FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????37. FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????38. FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????39. FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????40. FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????41. FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????42. FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????43. FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????44. FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????45. FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????46. FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????47. FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????48. FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????49. FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????50. FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????*PT = part-time (check box for employees working 20 hours per week or less)** National Provider Identifier number ................
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