Nanny/Care Agency Supplemental Application Nanny/Care Agency Supplemental Application INSTRUCTIONS Answer ALL questions completely, leaving no blanks. If any questions, or any part thereof, do not apply, show “N/A” in the appropriate space. This application must be completed and signed by an authorized partner, officer or other principal of applicant shown in Question 1.1 of this application. I. APPLICANT INFORMATION 1.1 Applicant (Proposed Named Insured): 1.2 Applicant Business Address 1.2 Applicant Business Address Street Address Street Address Suite/Bldg/Floor Suite/Bldg/Floor City City State State Zip/Postal Zip/Postal 1.3 Contact Person 1.3 Contact Person First Name First Name Last Name Last Name Email 1.4 Website/URL Date Company was Established II.GENERAL BUSINESS INFORMATION 2.1 Does the applicant currently hold any contracts with organizations requiring specific limits of insurance? Yes No If yes, please provide details (use a separate sheet if needed). 2.15 Does the applicant have any controls and procedures in place for Abuse & Misconduct? Yes No If yes, please describe. 2.2 Does the applicant have a formalized employee verification program, including local/state/federal background checks performed prior to hire? Yes No 2.3 Does the applicant and all professionals working on applicant’s behalf maintain current professional licenses or certifications in accordance with applicable local, state and federal laws and regulations? Yes No 2.4 Please indicate the percentage of the applicant’s total annual working hours that are spent providing healthcare services at each type of facility listed below. Total should equal 100%. Adult Day Care Center 010050 Assisted Living Centers 010050 Hotels 010050 Private Homes 010050 Event Care 010050 Other 010050 If other, please describe. 2.5 Does the applicant provide sitter services? Yes No 2.6 Does the applicant have a formalized complaint review procedure? Yes No If yes, does the applicant make appropriate changes in procedures and staffing based on its findings? Yes No III. PROFESSIONAL SERVICES Please conduct due diligence prior to completing the information below to ensure that it is accurate. The following information is critical to make an accurate assessment of the applicant’s exposure. 3.1 Please provide the current and projected revenue for each type of service listed below, for the current policy period and the next projected policy period. Type of Service Annual RevenuesCurrent Policy Period Annual RevenuesNext Policy Period (Projected) Childcare Services Childcare Services Rehabilitation (Occupational, Physical, Speech) Rehabilitation (Occupational, Physical, Speech) Skilled Care (including Alzheimer’s, Dementia, etc.) Skilled Care (including Alzheimer’s, Dementia, etc.) Specialized care Specialized care Other (Please describe.) Other (Please describe.) Please indicate if the applicant has an active membership in the following organizations. APNA INA 3.3 Does the applicant currently carry any insurance protection for general or professional liability? If so with whom? What is the retroactive date of current coverage? IV. PROFESSIONAL STAFF Please provide the number of staff applicant currently employs or contracts with in each category below, as well as the other information requested. Staffing Position Childcare (Placements, Annual) Full-time Childcare (Placements, Annual) Employees Part-time Childcare (Placements, Annual) Employees Full-time Childcare (Placements, Annual) Contractors Part-time Childcare (Placements, Annual) Contractors How many FT and PT Childcare (Placements, Annual) employees and contractors CARRY their own insurance coverage? How many FT and PT Childcare (Placements, Annual) employees and contractors DON'T CARRY their own insurance coverage? Total numbers of hours worked annually by FT and PT Childcare (Placements, Annual) employees and contractors Annual payroll (or IRS Form 1099 amount) for FT and PT Childcare (Placements, Annual) employees and contractors Childcare (Direct Hire Staff) Full-time Childcare (Direct Hire Staff) Employees Part-time Childcare (Direct Hire Staff) Employees Full-time Childcare (Direct Hire Staff) Contractors Part-time Childcare (Direct Hire Staff) Contractors How many FT and PT Childcare (Direct Hire Staff) employees and contractors CARRY their own insurance coverage? How many FT and PT Childcare (Direct Hire Staff) employees and contractors DON'T CARRY their own insurance coverage? Total numbers of hours worked annually by Childcare (Direct Hire Staff) FT and PT employees and contractors Annual payroll (or IRS Form 1099 amount) for FT and PT Childcare (Direct Hire Staff) employees and contractors Clerical/Office Staff Full-time Clerical/Office Staff Employees Part-time Clerical/Office Staff Employees Full-time Clerical/Office Staff Contractors Part-time Clerical/Office Staff Contractors How many FT and PT Clerical/Office Staff employees and contractors CARRY their own insurance coverage? How many FT and PT Clerical/Office Staff employees and contractors DON'T CARRY their own insurance coverage? Total numbers of hours worked annually by FT and PT Clerical/Office Staff employees and contractors Annual payroll (or IRS Form 1099 amount) for FT and PT Clerical/Office Staff employees and contractors Domestic Employee (Placements) Full-time Domestic Employee (Placements) Employees Part-time Domestic Employee (Placements) Employees Full-time Domestic Employee (Placements) Contractors Part-time Domestic Employee (Placements) Contractors How many FT and PT Domestic Employee (Placements) employees and contractors CARRY their own insurance coverage? How many FT and PT Domestic Employee (Placements) employees and contractors DON'T CARRY their own insurance coverage? Total numbers of hours worked annually by FT and PT Domestic Employee (Placements) employees and contractors Annual payroll (or IRS Form 1099 amount) for Domestic Employee (Placements)FT and PT employees and contractors Home Health Aide Full-time Home Health Aide Employees Part-time Home Health Aide Employees Full-time Home Health Aide Contractors Part-time Home Health Aide Contractors How many FT and PT Home Health Aide employees and contractors CARRY their own insurance coverage? How many FT and PT employees and contractors DON'T CARRY their own insurance coverage? Total numbers of hours worked annually by FT and PT employees and contractors Annual payroll (or IRS Form 1099 amount) for Home Health Aide FT and PT employees and contractors Sitters (Direct Hire) Full-time Sitters (Direct Hire) Employees Part-time Sitters (Direct Hire) Employees Full-time Sitters (Direct Hire) Contractors Part-time Sitters (Direct Hire) Contractors How many FT and PT Sitters (Direct Hire) employees and contractors CARRY their own insurance coverage? How many FT and PT Sitters (Direct Hire) employees and contractors DON'T CARRY their own insurance coverage? Total numbers of hours worked annually by FT and PT Sitters (Direct Hire) employees and contractors Annual payroll (or IRS Form 1099 amount) for FT and PT Sitters (Direct Hire) employees and contractors Sitters (Placement Only) Full-time Sitters (Placement Only) Employees Part-time Sitters (Placement Only) Employees Full-time Sitters (Placement Only) Contractors Part-time Sitters (Placement Only) Contractors How many FT and PT Sitters (Placement Only) employees and contractors CARRY their own insurance coverage? How many FT and PT Sitters (Placement Only) employees and contractors DON'T CARRY their own insurance coverage? Total numbers of hours worked annually by FT and PT Sitters (Placement Only) employees and contractors Annual payroll (or IRS Form 1099 amount) for FT and PT Sitters (Placement Only) employees and contractors Nurse Practitioner or RN Full-time Nurse Practitioner or RN Employees Part-time Nurse Practitioner or RN Employees Full-time Nurse Practitioner or RN Contractors Part-time Nurse Practitioner or RN Contractors How many FT and PT Nurse Practitioner or RN employees and contractors CARRY their own insurance coverage? How many FT and PT Nurse Practitioner or RN employees and contractors DON'T CARRY their own insurance coverage? Total numbers of hours worked annually by FT and PT Nurse Practitioner or RN employees and contractors Annual payroll (or IRS Form 1099 amount) for FT and PT Nurse Practitioner or RN employees and contractors V. CLAIMS AND INCIDENTS Please respond to the following questions to the best of your knowledge and belief, after conducting due diligence and inquiry with any individuals who may have knowledge or information about the matters described below. The term “applicant” as used below, means any proposed insured, including any individual or entity for whom coverage is sought. 5.1 During the past five (5) years, has the applicant received notice of any claim, suit, legal proceeding or regulatory/licensure action against any proposed insured relating to professional services, or for which coverage may be sought under the policy applied for? Yes No 5.2 Is applicant aware of ANY claims, suits, proceedings, investigations, complaints or allegations of negligence or misconduct (including those of abuse or molestation) made against applicant organization, or against anyone working on applicant’s behalf, brought or made against any proposed insured in the past five (5) years? Yes No 5.3 Within the past five (5) years, has the applicant given written notice to any current or prior professional or general liability insurance carrier of any claim, suit, legal proceeding or regulatory/licensure action, or of any facts, circumstances or situations which might give rise to a claim, suit, legal proceeding or regulatory/licensure action against any proposed insured relating to professional services? Yes No 5.4 Is the applicant or any proposed insured aware of any facts, circumstances, situations, transactions, events, acts, errors or omissions which could reasonably be expected to give rise to a claim, suit, legal proceeding or regulatory/licensure action against any proposed insured relating to professional services, or for which coverage may be sought under the policy applied for? Yes No IF THE RESPONSE WAS “YES” TO ANY OF THE ABOVE QUESTIONS IN SECTION V. ABOVE, PLEASE PROVIDE A CLAIM SUPPLEMENT OR COMPLETE DETAILS IN AN ATTACHMENT. PLEASE INCLUDE THE NAMES OF ALL PERSONS INVOLVED, THE ALLEGATIONS MADE, THE TIME, PLACE AND NATURE OF THE CIRCUMSTANCES OR INCIDENTS, AND A DESCRIPTION OF THE POTENTIAL LOSS OR DAMAGES CLAIMED. The policy applied for, if issued, will not insure: any claim, suit, legal proceeding, regulatory proceeding or investigation, or licensure action or investigation disclosed, or which should have been disclosed, in response to the above; or any claim, suit, legal proceeding, regulatory proceeding or investigation, or licensure action or investigation that arises from any fact, circumstance, situation, transaction, event, act, error or omission disclosed, or which should have been disclosed, in response to the above. FRAUD WARNINGS 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 and subjects that person to criminal and civil penalties. APPLICABLE IN AL, AR, DC, LA, MD, NM, RI AND WV Any person who knowingly (or willfully)* presents a false or fraudulent claim for payment of a loss or benefit or 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.*Applies in MD only. APPLICABLE IN CA For your protection, California law requires the following to appear on this form: Any person who knowingly presents false or fraudulent information to obtain oramend insurance coverage or to make a claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison. APPLICABLE IN CO 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. APPLICABLE IN FL AND OK 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)*.*Applies in FL only. APPLICABLE IN KS 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, electronic, electronic impulse, facsimile, magnetic, oral, or telephonic communication or 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. APPLICABLE IN KY, NY, OH AND PA 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 (not to exceed five thousand dollars and the stated value of the claim for each such violation)*.*Applies in NY only. APPLICABLE IN ME, TN, VA AND WA 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 and denial of insurance benefits.*Applies in ME only. APPLICABLE IN NJ Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties. APPLICABLE IN OR Any person who knowingly and with intent to defraud or solicit another to defraud the insurer by submitting an application containing a false statement as to any material fact may be violating state law. APPLICABLE IN VT 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. REPRESENTATIONS AND SIGNATURE By signing this application, the undersigned represents, on behalf of the applicant and all proposed insureds, the following: a. After conducting due diligence, the statements in the application and supplemental application furnished to the insurer are accurate and complete; b.Those statements furnished to the Insurer are representations applicant makes on behalf of all proposed Insureds; c.Those representations are a material inducement to the insurer to provide a premium proposal; d.If a policy is issued, the insurer will have issued this policy in reliance upon those representations; e.If there is any material change in the applicant’s condition or in the applicant’s activities, services, or answers provided in this application that occurs or is discovered between the date this application is signed and the effective date of any policy, if issued, applicant will immediately report such material change to the Insurer in writing; and f.The insurer reserves the right, upon receipt of such notice, to change or rescind any insurance proposal previously offered by the insurer. As used above, the term “insurer” refers to GTM Insurance Agency. NOTHING IN THIS APPLICATION SHOULD BE INTERPRETED TO MEAN THAT COVERAGE WILL BE OFFERED OR THAT ANY ITEMS REFERENCED IN QUESTIONS OR ANSWERS TO QUESTIONS WILL BE COVERED EVEN IF COVERAGE IS OFFERED AND BOUND. This application must be signed by an authorized partner, officer or other principal of applicant shown in question 1.1 of this application. Type name of authorized representative * Type name of authorized representative First Name First Name Last Name Last Name Title * Date * Submit If you are human, leave this field blank.
