Products/Completed Operations, Professional and/or General Liability Insurance for HME Dealer, Pharmacy & Sleep Lab

 

Proposed Effective Date: _________________________

Named Insured (full name of all companies to be insured under this policy):

__________________________________________________________________________________________

DBA: ____________________________________________________________________________________

Street:   _________________________________________________________________________

P.O. Box:_____________________________

City:_____________________________________             State:__________      Zip Code:_______________

Contact:_______________________Person:____________________________________Email:______________________________________________________________________________________________________ Phone#:____________________________________________________________________________________________________ ______________________________________________________________________________________________________ Fax#______________________________________________________________________________________________________

FEIN: _________________________ Medicare Provider No.: __________________________________

NPI No.:__________________________

 

Entity is:  Corporation  Individual  Partnership  Limited Partnership  LLC  Other________

1.   How many years experience in field? ________

2.   How many years operating under same company name? __________________

3.   Are you a subsidiary of another entity or do you have any subsidiaries   r Yes   r No

     If yes, please explain_____________________________________________________________________

4.   Have you ever carried insurance that was written on a “claims made” basis?  r Yes   r No

      If Claims Made – Retro Date:  ____/____/____

5.   Limit of Liability requested:         r $300,000/$300,000         r $500,000/$500,000         r $1Mil/$1Mil

r $1Mil/$2Mil r $1Mil/$3Mil           r $2Mil/$3Mil                     r $2Mil/$4Mil             r $3Mil/4Mil

r $4Mil/4Mil               r $5Mil/$5Mil

Gross Revenue

Estimated Annual Gross Receipts for the Upcoming Year: $ ____________

                                                                  Previous Year: $ _____________

 

 

Rev 10-2008

 

 

Inventory (products sold or rented or services rendered)

Gross Revenue must be broken into percentages and must equal 100%

 

Equipment Sales/Rentals:			Wheelchairs			Services:
Apnea Monitor		%	Wheelchair Lifts		%	Sleep Study		%
Liquid Oxygen		%			%	Pharmacy		%
Oxygen Cylinder		%			%	Repair & Service		%
Parenteral Therapy		%	Braces		%	Other Svc. (please list)		%
Scooters/TriCarts		%	CPAP		%
Ventilators		%	Grab/Safety Bars		%
Defibrillators		%	ADLs		%	Permanent Installation*:
Diabetic Shoes		%	Latex Gloves		%	Elevators		%
			LAL Mattress		%	Ramps		%
Beds, Walkers, Crutches		%	Nebulizers		%	Ceiling Lifts		%
CPM’s		%	TENS		%	Stair Lifts		%
Enteral Therapy		%	Uniforms		%	Wheelchair Lifts		%
Lift Chairs		%	Diabetes Monitoring		%	Hand Controls in Autos		%
Motorized Wheelchairs		%	Diabetes Testing		%	Wheelchair Lifts in Autos		%
Oxygen Concentrators		%	Disposables		%	Grab Bars		%
Stair/Ceiling Lifts		%	Other		%	Other Permanent Install		%
					%
“Installation of fixtures and equipment” means the permanent installation of equipment and fixtures attached to, or a part of, any building, structure or auto.

  6.   Do you customize, modify or repair any products?   r Yes   r No

        If yes, which items? ______________________________________________________________________

7.      Are you accredited by JCAHO, CHAP, ACHC, HQAA, CEAC? Please circle if applicable

8.      Do you use any independent contractors for your business (1099’s)?  r Yes   r No           If yes, in what capacity? __________________________________________________________________

  9.   Do you employ contract or subcontract labor for installation, service or repair of products? r Yes r No

        If yes, which products? ___________________________________________________________________

10.   Do you sell or rent products or provide services to hotels, resorts, casinos or other retailers (i.e.: Wal-Mart,

     Kmart, etc.)?  r Yes   r No

        If yes, please list businesses _______________________________________________________________

11.   Do you draw plans, designs, or specifications for any products sold?  r Yes   r No

       If yes, which products? ___________________________________________________________________

12.   Do you manufacture any products?  r Yes   r No

13.   Do you provide warranties or guarantees other than those provided by manufacturers?  r Yes   r No

 

14.   Please check if you would like a quote for:      

       Hired and/or Non-Owned Auto¹ $250,000 limits r      Employee Benefits Liability² $1,000,000 limits r        

      ¹Supplemental Application Required                            ²Number of employees________________

 

Rev 10-2008

 

Professional Liability

15.   Please state number of certified professionals by category:

Respiratory Therapists ______ Nurses ______ Pharmacists ______ Occupational/Physical Therapists_____

Describe their function: _________________________________________________________________________________________ 

16.   Do you charge a fee for respiratory therapy services separate from the sale or rental of equipment?

          r Yes r No

17.  Do Pharmacists carry their own individual professional policy?   r Yes   r No

18.  Is the pharmacy owner a registered pharmacist?  r Yes   r No

19.  Are tests administed by a certified Polysomnographic Technologiest (PST)?  Yes    No

20.  Do you employ a medical director?  Yes    No   Medical director’s name:_______________________

 

Prior Liability Insurance Experience

Carrier Name ______________________________________Year:____________ Premium:______________

Carrier Name ______________________________________Year:____________ Premium:______________

 

21.   Have there been any claims filed or losses paid, or are you aware of any incidents which might give rise to a suit against you, within the last three (3) years?

r Yes r No   If yes, please describe below or attach sheet or

 

 

prior carrier loss history

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

Location Information

 

 

Rev 10-2008

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

The Warranties following will be made a part of any policy issued under this program.

 

WARRANTED:  The Company named on the front hereof and as signed below does not engage in any of the following activities:

 

A.                 Manufacture of any product.

B.                 Re-Manufacture or re-building of any item (repairs allowed – see below)

C.                 Provide home health nursing, therapy or other medical or quasi-medical services of any kind.

D.                 Charge a fee for medically related services.

E.                  Sell or rent significant volumes of imported product (significant is deemed to be in excess of 5%)

F.                  Directly import any product.

 

WARRANTED:  The Company named on the front hereof and as named below will adhere to the

following quality criteria to be eligible for (and remain eligible for) coverage under this insurance program:

         

A.                 Repair work allowed on owned or rented equipment only, by trained personnel and following manufacturers recommendations.  No significant outside repair work is allowed. 

B.                 The insured provides no express or implied warranties of mercantability, fitness for use, or safety other than those warranties insured is expressly authorized to provide as an agent on behalf of the manufacturer, by the manufacturer.    

C.                 If oxygen is offered a true 24-hour service program must exist.       

D.                 Insured must have and designate a “Safety Manager” to receive, catalog and disseminate all safety and loss control information.  

E.                  No injections or I.V. administration may be done by an insured unless the individual so doing is properly licensed and the administration is incidental to the sale or rental of the equipment and not on a fee basis.  

F.                  Permanent installation of equipment must be disclosed and specifically approved by Insurer.

G.                 Customer agrees to no leasing or rental of equipment in off premises retail locations (malls, large retailers, hotels, resorts, casinos, etc.) without direct involvement of employed or subcontracted staff at the delivery point.

                  

WARNING!!  This is an important document, which could affect your legal rights.  Please read it again carefully and be certain it is correct and complete.  Your signature below is your warranty to us that we can rely on this form.  We have made no investigation of our own and the coverage decision will be based on this information.  COVERAGE IS NOT BOUND OR STARTED BY THIS FORM.  WE MAKE NO PROMISE TO INSURE.  THIS IS ONLY A REQUEST FOR A QUOTE.  YOU ARE NOT COVERED UNTIL AND UNLESS YOU RECEIVE A BINDER SO STATING.

 

The coverages that we are quoting from information on this form are Product/Completed Operations & Professional and/or General Liability Insurance.  We base important decisions on your answers to these questions. We rely on the accuracy of your answers.  If you have any questions about the form or your answers please ask your sales representative.

The questions in this application are not intended to, nor do they, indicate the existence, non-existence or limitations on any items of coverage.  This document does not in any fashion determine the coverage provided.

 

INCOMPLETE APPLICATIONS WILL BE REJECTED

 

Signature and Attestation:                                          

 

Name (Print): ______________________________

                                                                  

Signature: ____________________________                           

 

Title: _____________________________________

 

Rev 10-2008 Date: _________/_________/_________