Evanston Insurance Company
  Markel American Insurance Company
  Markel Insurance Company

		
APPLICATION FOR ADULT DAYCARE CENTERS PROFESSIONAL AND GENERAL LIABILITY INSURANCE
APPLICANT’S INSTRUCTIONS:
1. Answer all questions. If the answer requires detail, please attach a separate sheet.
2. Application must be signed and dated by owner, partner or officer.
3. PLEASE READ CAREFULLY THE STATEMENTS AT THE END OF THIS APPLICATION.
(PLEASE TYPE OR PRINT IN INK)
ADDITIONAL DOCUMENTS TO BE SUBMITTED WITH EVERY APPLICATION
1.  Is sample employment application attached?
2.  Is sample advertising brochure attached?
3.  Are current audited financial statements attached?
1.	APPLICANT INFORMATION
	a.	Full name of applicant: 	
Please attach a list of entities to be considered as additional insureds including brief explanations of their interests, operations and relationship to applicant.
	b.	Principal business premise address: 	
				(Street)		(County)
	
			(City)	(State)	(Zip)
		Please attach list of additional locations.
	c.	Phone Number: (     ) 		
	d.	Requested Limits of Liability: $___________ Per Claim   $____________ Annual Aggregate   Deductible: 	
	e.	[  ] Individual  [  ] Corporation  [  ] For Profit  [  ] Partnership  [  ] Governmental  [  ] Not for Profit  [  ] Other 	
2.	APPLICANT OPERATIONS
	a.	Number of years this facility has been: 
		(i)	Operating: _______   (ii)  Owned by current owners: _______   (iii)  Managed by current management: 	
	b.	Are you:
		(i)	Licensed and certified as required by state and/or federal law?	YES   NO
		(ii)	Licensed and approved by State Board of Health?	YES   NO
		(iii)	Licensed by State Department on Aging?	YES   NO
		(iv)	A member of a state or national association?	YES   NO
	c.	What is the maximum number of clients permitted by license? ______
	d.	Has the Applicant entered into any written indemnification agreements:
		(i)	Holding the applicant harmless?	YES   NO
		(ii)	Holding any other party harmless?	YES   NO
		If Yes, to (i) or (ii) attach copies of agreements.
	e.	Gross Revenues:
			Past 12 Months	Next 12 Months
		Medicaid	$		$	
		Medicare	$		$	
		Private Pay	$		$	
		Charitable	$		$	
		Total	$		$	
3.	APPLICANT MANAGEMENT
	a.	Please complete the following:
	Director	Medical
	of Nursing	Director	Administrator
		Employed	____________	____________	____________
		Contracted	____________	____________	____________
		Full-Time	____________	____________	____________
		Part-Time	____________	____________	____________
		Years at this Facility	____________	____________	____________
		Years Experience	____________	____________	____________
	b.	Please provide name and qualifications of Medical Director: 	
			
	c.	Does the applicant want to include coverage for the Medical Director?	YES   NO
	d.	Do you report known or suspected incidents of abuse to local health or law enforcement agency?	YES   NO
	e.	Do you have regularly scheduled staff meetings?	YES   NO
		If Yes, please indicate frequency: ____________________
	f.	Are written procedures in effect for incident reporting?	YES   NO
	g.	Please provide name and title of the individual responsible for reviewing incident report and determining whether corrective action is necessary: 	
			
	h.	Is the Applicant a “Covered Entity” under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy Rule?	YES   NO
		If Yes,
			(i)	Has the Applicant implemented procedures to comply with the HIPAA Privacy Rule?	YES   NO
			(ii)	Provide the name and title of the Applicant’s Privacy Officer.	
Our Business Associate Agreement is available at https://www.markelcorp.com/US-Insurance/HIPAA. This is the only Business Associate Agreement we will recognize.
4.	APPLICANT PROCEDURES
	a.	Please attach a description of the procedure for storing and dispensing medication.
	b.	Please attach the following:
		(i)	description of precautions taken to prevent clients from leaving premises without proper authorization.
		(ii)	description of precautions taken to prevent clients from being released to unauthorized persons.
		(iii)	description of precautions taken to prevent clients from accessing cooking areas, stoves, kilns.
	c.	Who determines if a client can no longer be served at the facility? 	
	d.	Are written attending physician orders required for:
		(i)	Dispensing of all drugs or medicines?	YES   NO
		(ii)	Special dietary requirements?	YES   NO
		(iii)	Any other specific therapy /treatment?	YES   NO
		(iv)	Use of restraints?	YES   NO
	e.	How long are client records maintained? __________________________________
	f.	Is a client assessment conducted for new clients?	YES   NO
		If Yes, does this assessment include evaluation of:
		(i)	Mobility limitations?	YES   NO
		(ii)	History of prior illnesses and injuries?	YES   NO
		(iii)	Required assistance?	YES   NO
		(iv)	Disorientation/combativeness?	YES   NO
		(v)	Current medications?	YES   NO
		(vi)	Continence?	YES   NO
5.	APPLICANT SERVICES/ACTIVITIES
	a.	Is the Center involved in any of the following:
		(i)	Fund raising activities?	YES  NO
		(ii)	Craft fairs?	YES  NO
		(iii)	Internships/Externships of health care students?	YES  NO
		If Yes, please attach description.
	b.	Does the Center provide the following services:
		(i)	Psychiatric assessments?	YES   NO
		(ii)	Mental health counseling?	YES   NO
		(iii)	Medical counseling?	YES   NO
		(iv)	Financial counseling?	YES   NO
		(v)	Alzheimer or dementia care?	YES   NO
		(vi)	Physical or occupational therapy?	YES   NO
		(vii)	Child or adolescent day care?	YES   NO
		(viii) Meals?	YES   NO
		If Yes, please attach description.
	c.	Are any offsite recreational or field trip activities undertaken?	YES   NO
6.	CLIENT PROFILE
	a.	What is the average number of clients per day?
	b.	Source of Payment:	# of Clients
		Medicaid	_________
		Medicare	_________
		Private Pay	_________
	c.	Age Group:	# of Clients	# Non-Ambulatory
		50-65 years old	_________	_________
		66-75 years old	_________	_________
		76-85 years old	_________	_________
		86-100 years old	_________	_________
		Over 100 yrs old	_________	_________
	d.	Do all clients have their own attending physician?	YES   NO
7.	APPLICANT TRANSPORTATION
	a.	How  are clients transported between their homes and the facility?
		(i)	Client is responsible for their own transportation?	YES   NO
		(ii)	Center contracts with third party to provide transportation?	YES   NO
		(iii)	Center provides transportation?	YES   NO
	b.	If Center contracts with third part to provide transportation:
		(i)	Is the vehicle equipped with a phone or two-way radio?	YES   NO
		(ii)	Are drivers trained in CPR and first aid?	YES   NO
		(iii)	Are certificates of insurance obtained?	YES   NO
	c.	If you provide transportation:
		(i)	Is the vehicle equipped with a phone or two-way radio?	YES   NO
		(ii)	Are drivers’ driving records checked?	YES   NO
		(iii)	Are drivers trained in CPR and first aid?	YES   NO
			How often? _______________________
		(iv)	Please provide name of automobile insurance carrier and limits carried: 	
				
8.	APPLICANT STAFF
	a.	Have you submitted a sample employment application?	YES  NO
	b.	Are criminal records checked for new hires?	YES  NO
	c.	Are personal references requested and checked?	YES  NO
	d.	Are prior employment references necessary?	YES  NO
	e.	For each classification listed please show the number of full/part-time employees and/or independent 	contractors.  (For part-time staff members, show the full-time equivalent.)
	Employees	Independent Contractors
		Part-Time		Part-Time
	Full-Time	(Full-Time	Full-Time	(Full-Time
		Equivalent) 		Equivalent)
Physicians on Staff	__________	__________	__________	__________
Physicians on Call	__________	__________	__________	__________
Dentists	__________	__________	__________	__________
Registered Nurses	__________	__________	__________	__________
Nurses Aides	__________	__________	__________	__________
Occupational/Physical Therapists	__________	__________	__________	__________
Dieticians	__________	__________	__________	__________
Beauticians/Barbers	__________	__________	__________	__________
Administrative/Clerical Personnel	__________	__________	__________	__________
Maintenance/Security Personnel	__________	__________	__________	__________
Social Workers	__________	__________	__________	__________
Counselors	__________	__________	__________	__________
Podiatrists	__________	__________	__________	__________
Other-describe
____________________________	__________	__________	__________	__________
Total Number of 
Employees/Independent
Contractors	__________	__________	__________	__________
9.	APPLICANT FACILITY
	a.	Is the facility equipped with:
		(i)	At least two clearly marked exits on each floor?	YES   NO
		(ii)	Self-closing fire doors on each floor?	YES   NO
		(iii)	Automatic fire alarm system connected to a local fire department?	YES   NO
		(iv)	Smoke detectors in:
			(A)	Common areas?	YES  NO
			(B)	Craftroom?	YES  NO
			(C)	Kitchen?	YES  NO
			(D)	Sleeping Rooms?	YES  NO
	b.	Building Description	Buildings/Wings
	#1	#2	#3	#4
	Type of Construction?	__________	__________	__________	__________
	No. of Stories? 	__________	__________	__________	__________
	Total Beds?	__________	__________	__________	__________
	Date Built:	__________	__________	__________	__________
	Complete or Partial	__________	__________	__________	__________
	Sprinkler System?	__________	__________	__________	__________
	c.	Evacuation procedures:
		(i)	Does the Center have a written emergency plan?	YES   NO
		(ii)	Are evacuation directions posted in all parts of the Center’s facility?	YES   NO
		(iii)	Does the staff orientation plan include a review and “walk through” of any disaster plan?	YES   NO
		(iv)	How often are evacuation/fire drills conducted?
	d.	Are handrails provided in hallways and bathrooms?	YES   NO
	e.	Do you have a written patient safety policy?	YES   NO
		If yes, attach a copy of this policy
	f.	Is smoking permitted in the facility?	YES   NO
10.	APPLICANT HISTORY
	a.	Has any insurance company ever canceled, non-renewed or declined to accept your professional
		liability insurance? 	YES   NO
		If Yes, please attach a detailed explanation.
	b.	Has the Center been the subject of investigatory or disciplinary proceedings or reprimand by
		an administrative or governmental  agency or professional association? 	YES   NO
	c.	Has the Center been the subject of any license suspension or revocation or been placed under
		probation?	YES   NO
		If Yes, please attach detailed explanation.
	d.	List prior professional insurance carried for each of the past five years.  IF NONE, STATE NONE.
Insurance Company	Policy Number	Limits of Liability	Deductible	Premium	Expiration
Mo/Day/Yr	Was this a Claims Made Policy Form?
	Yes	No	Retro Date	
						[   ]	[   ]		
						[   ]	[   ]		
						[   ]	[   ]		
						[   ]	[   ]		
						[   ]	[   ]		
	e.	List prior general insurance carried for each of the past five years.  IF NONE, STATE NONE.
Insurance Company	Policy Number	Limits of Liability	Deductible	Premium	Expiration
Mo/Day/Yr	Was this a Claims Made Policy Form?
	Yes	No	Retro Date	
						[   ]	[   ]		
						[   ]	[   ]		
						[   ]	[   ]		
						[   ]	[   ]		
						[   ]	[   ]		
11.	CLAIMS
	a.	Has any professional liability claim or suit been brought against the Center and/or any of its employees?	YES   NO
		If Yes, please submit:
		(i)	A fully completed Supplemental Claim Information form (SM174-2 10/92) for each claim or suit.
		(ii)	Professional liability loss experience, currently valued, from the applicant’s prior professional liability insurance carrier for each of the last five (5) years.
	b.	Is the applicant aware of any circumstances which may result in a professional liability claim or suit
		being made or brought against the applicant or any of its employees?	YES   NO
		If Yes, attach a detailed explanation.
	c.	Has any general liability claim or suit been brought against you and/or any of your employees?	YES   NO
		If Yes, please submit:
		(i)	A fully completed Supplemental claim Information form (SM174-2 0/92) for each claim or suit.
		(ii)	General liability loss experience, currently valued, from your prior professional liability insurance carrier for each of the last five (5) years.
NOTICE TO APPLICANT: The coverage applied for is SOLELY AS STATED IN THE POLICY, which provides coverage on a "CLAIMS MADE" basis for ONLY THOSE CLAIMS THAT ARE FIRST MADE AGAINST THE INSURED DURING THE POLICY PERIOD unless the extended reporting period option is exercised in accordance with the terms of the policy.
Any person who knowingly defrauds any insurance company by filing an application for insurance containing any false information or concealing, for the purpose of misleading, information concerning any fact thereto commits a fraudulent insurance act, which is subject to criminal and civil penalties.
WARRANTY: I warrant to the Insurer, that I understand and accept the notice stated above and that the information contained herein is true and that it shall be the basis of the policy of insurance and deemed incorporated therein, should the Insurer evidence its acceptance of this application by issuance of a policy. I authorize the release of claim information from any prior insurer to the underwriting manager, Company and/or affiliates thereof.

Name of Applicant		Title (Officer, partner, etc.)

Signature of Applicant		Date

SIGNING this application does not bind the Applicant or the Insurer or the Underwriting Manager to complete the insurance, but one copy of this application will be attached to the policy, if issued.