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HOME HEALTH CARE QUESTIONNAIRE Name of organization: _______________________________________________________________________ Address: __________________________________________________________________________________ City: ___________________________________ State: _________________________ Zip code: ____________ Website address (URL): ______________________________________________________________________ Date Business operations started: ______/______/_____ Inspection Contact: _________________________ Phone: ________________ email: ___________________ Applicant is a:

Corporation Partnership Professional Association Sole Proprietorship Joint Venture Other (Please Explain) ___________________________

SUBMISSION REQUIREMENTS ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪

Home Health Care Questionnaire ACORD applications 5 years of currently valued carrier loss runs Copy of State (s) Home Health Care License (s) and most recent State Licensure survey Brochures Copy of all Federal and State complaint investigation reports in the last 12 months Client Contract/Service Agreement: Provide copies of Indemnification Agreement, Hold Harmless Agreement and Additional Insured Provisions Resume of owner/principle if less than 3 years in business

CLAIMS HISTORY Are you aware of any circumstance which may result in a general liability, abuse and molestation or professional liability claim or suit being made against you?

YES

NO

Have any claims been filed against your organization or anyone working on behalf of your organization?

YES

NO

Please list the general liability, abuse and molestation, and/or professional liability carrier for each of the past three years. If none, state “none.” Insurance Company

Policy Number

Limits of Liability

Deductible

Premium

Policy Period

Claims-Made? Yes

No

Retro Date _______ Yes No Retro Date _______ Yes No Retro Date _______

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APPLICANT INFORMATION Home Health Care: Medical Companion/Sitter Durable Medical Equipment Location of Services Provided: Type Assisted Living Facilities ____% Clinics Hospice

____% ____%

Staffing Agency Visiting Nursing Associations

Type Hospitals Nursing Homes Private Homes

Type ____% ____% ____%

Other ________________

Above must total 100%

Types of Services Provided: Service Adult Day Care Chemotherapy Clergy Companion/Sitter Dialysis Dispensing of medication Other 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15.

Service ____% ____% ____% ____% ____% ____% ____%

Durable Medical Equipment ____% Hospice ____% Pediatric Care ____% Personal Care ____% Skilled Nursing care ____% Ventilator Care ____% Wound Care ____%

Total annual gross revenue/operating budget: __________________ Total payroll of employees: ______________ Annual number of home visits: _____________ Total receipts of independent contractors: ________________________ Is the business licensed by regulatory authorities? Attach copy of license. What was the date of last inspection by licensing agency? _____/____/____ Are all employees who visit clients bonded? Do you require and keep certificates of insurance for all independent contractors? Has any agency employee ever been reprimanded, refused admission or suspended by any association or administrative agency? Has the agency’s license ever been suspended, revoked or made conditional by any association, administrative or regulatory agency? Does your agency have a written contract with service providers? Are “hold harmless” agreements in your favor part of the contract between your organization and service providers? Does your organization require service providers name you as “additional insured” under the provider’s policy? Is documentation of all homecare training provided? Is the Applicant accredited or a member of any Health Care Organization? If yes, who? _____________________________________

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Service Therapy:

Infusion Occupational Physical Radiation Respiratory Speech

____% ____% ____% ____% ____% ____%

Other

YES

NO

YES YES

NO NO

YES

NO

YES YES

NO NO

YES

NO

YES YES YES

NO NO NO

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ABUSE AND MOLESTATION COVERAGE

16. Abuse Limit requested: $___________________________ 17. Type of abuse coverage currently in place: None Included in GL or Sublimit:_________________ Occurrence Included in GL or Sublimit:_________________ Claims Made 18. Have any claims been filed or allegations been made, against your organization or anyone working on behalf of your organization alleging abuse? YES NO NO 19. Are you aware of any occurrences that could lead to a claim? YES If yes, to above, attach explanation 20. Does your organization have written policies that require known or suspected abuse incidents be reported to proper authorities? YES NO Total number of clients in each age range: 0-8 years: _____ 9-18years: _____ 19-39 years: _____ 40-65 years: _____ 66-79 years: _____ 80+ years: _____ Employees

Volunteers

a.

Is unsupervised contact allowed with clients?

YES

NO

YES

NO

b.

Education verified?

YES

NO

YES

NO

c.

Personal references checked?

YES

NO

YES

NO

d. e.

Written application required?

YES

NO

YES

NO

State 10-digit fingerprint criminal record check?

YES

NO

YES

NO

f.

Federal 10-digit fingerprint criminal record check if in state less than 5 years? Federal 10-digit fingerprint criminal record check regardless of time in state? Are all controls indicated in d-g required prior to any client contact? How long are records kept documenting all screening activities outlined above?

YES

NO

YES

NO

YES

NO

YES

NO

YES

NO

YES

NO

g. h. i.

_____ years

_____ years

If no to any questions b. – h. above, explain all no responses: _______________________________________ __________________________________________________________________________________________

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PROFESSIONAL LIABILITY COVERAGE 21. Of the professionals listed, employees and independent contractors, do any carry their own professional liability insurance? a) Do you maintain a copy of current certificate of insurance and state license? 22. Do you maintain copies of licenses for all employed professionals that are required to be licensed? 23. List number of employees and independent contractors (full or part-time) by position below:

Number of Employees

Number of Ind Contractors

YES YES

NO NO

YES

NO

Est. Annual Payroll

Name of Position Full Time

Part Time

Full Time

Part Time

Employees

Contractors

A complete treatment plan prescribed by a physician, including follow-up plans? A written plan of care provided to the patient or family members? An “informed consent” document obtained and placed in the patient’s medical record? (informed consent laws vary by state) Patient care home visits meticulously documented? Complete medical records maintained on all patients, beginning at the point of referral? Patient records kept on file (hardcopy of electronic) for a minimum of 6 years? All changes in condition and incidents documented to the physician and family? Medications and dosage, including documentation of administering medications? A copy of literature given to clients explaining services and fees? Termination of services and discharge criteria?

YES YES YES

NO NO NO

YES YES YES YES YES YES YES

NO NO NO NO NO NO NO

Administrator/Clerical Counselor/Social Worker Home Health Aide/C N A/ N A Nurse Practitioner/Physician Asst Nurse – RN/LPN Nutritionist/Dietician Pharmacist? Therapist – Occupational Therapist – Physical Therapist - Respiratory Therapist – Speech / Hearing Therapist – Other Other Positions (specify)

RISK MANAGEMENT 24. Do patient records include the following? a) b) c) d) e) f) g) h) i) j)

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AUTO COVERAGE 25. Does your organization own or lease vehicles? 26. Are all owned or leased vehicles being submitted to us for coverage? If yes, attach Acord® Auto applications. 27. Do you provide transportation to and from your facility? 28. Does your organization prohibit employees and volunteers from driving on your behalf if their MVR indicates any of the following: a) a. More than 2 moving violations and/or accidents within a 3 year period? b) b. Reckless driving, DUI or any felony driving conviction within a 5 year period? 29. Are any vehicles equipped with wheelchair lifts? If yes, have employees been trained in use? 30. Is hired auto liability coverage desired? If yes, does your annual vehicle rental expense exceed $2,500? If yes, what is your annual vehicle rental expense? _____________________ 31. Is non-owned auto liability coverage desired? If yes, Total number of: ____ employees ____volunteers 32. Complete the following chart, indicating number of employees and volunteers that use their personal vehicles on behalf of your organization.

Usage

Number of Volunteers

Number of Employees

Average trips per week (total for all employees & Volunteers)

Annual MVR Required?

Proof of Personal Auto Insurance Required on a Renewal Basis?

YES YES

NO NO

YES

NO

YES YES YES YES YES YES

NO NO NO NO NO NO

YES

NO

100/300 or 300 CSL Personal Auto Limits Required?

YES

NO

YES

NO

YES

NO

Transport Clients

YES

NO

YES

NO

YES

NO

Home visitation

YES

NO

YES

NO

YES

NO

Home Meal Delivery

YES

NO

YES

NO

YES

NO

Other ______ ___________

YES

NO

YES

NO

YES

NO

Errands

WARRANTY, AUTHORIZED SIGNATURE AND CONTINUING DUTY TO UPDATE The undersigned is an authorized representative of the prospective Named Insured, and acknowledges that the information provided with the Application, including all questionnaires, supplements, attachments, and replies to underwriter inquiries, and applications from other insurance companies which have been submitted to Great American and made part of this application: 1. Will be relied upon by Great American Insurance Group insurers in determining the acceptability of the prospective Named Insured and the premium amount to be charged; 2. Are true, accurate and complete; and 3. Will be considered an integral part of any resultant insurance contract. The undersigned further agrees that the prospective Named Insured has a continuing duty, through the date of policy inception, to update this Application, including all questionnaires, supplements, attachments and replies to underwriter inquiries. Signature, printed name and title of authorized representative of applicant and date signed: Signed: ________________________________________

Name: ____________________________________

Title: __________________________________________

Date: _____________________________________

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