Home Health Care Agencies

Agent Information

Agency Name

-OR-

Agent Lookup Code

Agent Names

Agent Name (first and last)

Phone:

Fax:

Agent Email:

Agency's Mailing Address

Agency City

Agency State

Agency Zip

Insured Information

Insured Name:

Insured Email:

Insured's Mailing Address

Suite, Unit, Floor, etc (optional)

Insured's City

Insured's State

Insured Zip

Is Location Address same as Mailing Address? (Click if Yes)

Location Address

Suite, Unit, Floor, etc. (Optional)

Location City

Location State

Location Zip

Classification (Receipts)

Home Health Care Services -- other than not for profit -- products/completed

Operations are subject to the general aggregate limit

Number of Professional Employees (Licensed Nurses, RN, LVN, LPN and Physical Therapists)

Professional Receipts (generated by Professionals)

Number of Non-Professional Employees (Nurse's Aides and Home Health Aides)

Non-Professional Receipts (generated by Employees)

Years of Experience

Limit Required

Is This a New Venture?

Any Infusion Therapy? (Click if Yes)

Any Contracted or Employed Physicians or Physicians Assistants? (Click if Yes)

Any Contracted or Employed Nurse Practitioners? (Click if Yes)

Any Contracted or Employed Birth or Postpartum Doulas? (Click if Yes)

Any Contracted or Employed Midwives? (Click if Yes)

Any Contracted or Employed Personal Trainers? (Click if Yes)

Any Uninsured Independent Contractors Performing Medical or Professional Care? (Click if Yes)

Any Service Provided to Clinics, Hospitals, Physician's Offices,Convalescent / Nursing Homes, Assisted Living Facilities, Hospices, Jails, Prisons, or Detention Centers? (Click if Yes)

Is the Insured hired by the Patient or Patient's Guardian directly for this service?

Does insured own and operate a pharmacy? (Click if Yes)

Does insured perform foster care placement? (Click if Yes)

Does insured perform any care in owned, leased, or rented premises? (Click if Yes)

Any Rental of Equipment or Supplies to Others? (Click if Yes)

More Than 2 Losses in the Last 3 Years? (Click if Yes)

Any Loss Exceeding $10,000 in the Last 3 Years? (Click if Yes)

Any Transportation Provided for Patients? (Click if Yes)

Does the insured confirm that personal auto coverage is in place? (Click if Yes)

Any Additional Insureds? (Click if Yes)

What type of additional insureds are needed?

Is Blanket Additional Insured Coverage needed?

How many additional insureds are needed?

Does insured hire subcontractors? (Click if Yes)

What percent of workers hired are subcontracted? (%)

Are subcontractors paid by the clients directly rather than the insured?

Total subcontractor Payroll/Cost to insured (in dollars):

Will insured need Terrorism Coverage?

Commission

What commission would you like for this account?

Additional Comments

Additional Comments: