IPMG - Nursing Home Liability Insurance Application

NURSING HOME LIABILITY INSURANCE APPLICATION

1. Insured Information
Applicant Name:
Address:
Address Continued:
City:	State
Zip Code:
Telephone:
Fax:
Contact:
Title:

Program Manager	City	State	Principal
Insurance Program Managers Group	St. Charles	IL	Gregg Peterson
Agent:
PART I - APPLICANT

Name	Web Site Address

Street Address	P.O. Box	County

City	State	Zip

Coverage Effective Dates

From:

To:

List any Subsidiaries to be Covered: Description of Subsidiary Operations:

PART II - LIMITS AND DEDUCTIBLES

A. PRIMARY LIABILITY LIMITS:

Professional and General Liability limits must be the same.

Professional Liability

$1,000,000 any one occurrence and $3,000,000 in the aggregate annually. Yes No

General Liability (Bodily Injury, Personal Injury, Property Damage and Advertising Injury)

$1,000,000 any one occurrence and $3,000,000 in the aggregate annually. Yes No

B. EXCESS LIABILITY LIMIT:
	If other is selected, please specify amount:

C. DEDUCTIBLES (Minimum $5,000):
Note: Where two amounts are shown, the second amount limits the total deductible payments during each annual period.
	If other is selected, please specify amount:

PART III - GENERAL INFORMATION

A. Application is: (Check all appropriate boxes)

Individual	Governmental	Charitable	Not for Profit
Partnership	Operated for Profit	Corporation

Is Facility approved/ has certification/ license ever been revoked or suspended (if so provide details):

Medicare Certified

Medicaid Certified

Accredited by JCAH

Licensed / Approval Type and Number:
State Board of Health and Expiration Date:

B. Number of years this facility has been:
	Operating:
	Owned by Present Owner:
	Managed by Present Management:

C. List all licenses held by your facility and their expiration dates:

D. List all asscociation memberships held by your faciltity:

PART IV - DESCRIPTION OF SERVICES

A. Facility Calssification and Bed Census

	No. of Ambulatory Patients	No. of Non-Ambulatory Patients	Licensed No. of Beds	Avg. Occupancy Rate
a) Skilled Nursing Home - Provides "skilled nursing care to patients as its primary and predominate function. This is the greatest degree of medical services outside of a hospital.
b) Personal Care Home - Or Home for the aged providing some "skilled nursing care" but only has an adjunct to its primary domicillary of assisting individuals with their everday essential activities.
c) Residential Care Home - Provides some "skilled nursing care" but only has an adjucnt to its primary "residential" or "sheltered" care function.
d) Combination Facility - Has identifiable sections in management. This facility may be involved in two reasonable close proximity and under the same overall or more of the categories described above.
e) Other - Describe fully the type of care provided separatley.

B. In addition to the above-described services, do you provide separate "independent living" accommodations?	Yes No
If Yes, please use the comment section to describe such facilities, including the number of residents and units.
C. Describe in the comment section any recreational building or equipment features at this location (i.e., swimming pools, exercise equipment, etc.) Number of swimming pools:

D. Describe any outpatient services provided by your family (i.e. home health care, physical therapy, etc.) including the number of visits per year:

E. Do you accept patients who are either chemically dependent, physically impaired or mentally / emotionally disturbed?
	Yes No
Patient / Resident Age Groups

Age Group	No. of Patients/Residents	% Non-Ambulatory
Under 50
50-60
Over 65

PART V - ADMINISTRATION STAFF

A. Administrator's Name and brief summary of administrative experience.

	Name:
	Experience:

B. Do you employ a full-time medical director?
	Yes No
	If Yes, briefly describe the director's medical qualifications:

D. For each classification listed below, show the number of employees (F/T - 1, P/T - 0.5)

Employees	No.	Employees	No.
Physicians		Interns
Dentists		Residents
Registered Nurses		Pharmacists
Licensed Pracitcal Nurses		Occupational Therapists
Nurse's Aides		Dieticians
Physical Therapists		X-Ray Technichians
Beauticians / Barbers		Volunteers
Administrative Personnel		Maintenance / Security
Others - Describe:		Total Number of Employees:

E. All Employeed Physicians, Independent Contract Physicians and attending Physicians are required to carry individual medical malpractice limits of at least $1 MM / $1 MM each.

Please attach schedule o physicians with limits carried and confirm how these limits confimed, i.e., annual sight of certificates of insurance.

F. Name of individual that our Risk Management Services representative may contact for an on-site inspection of your facility.

Name:
Phone Number:

PART VI - RULES AND PROCEDURES

A. Do you require evidence of acceptable health (physical examination) of all new patients admitted to your facility? Yes     No

B. Evacuation Procedures:

Are any Non-Ambulatory patients above the ground floor? Yes     No

Do you have a written emergency evacuation plan? Yes     No

Does your plan include advance in arrangments for transportation and temporary shelter? Yes     No

Are evacuation directions posted in all parts of your facility? Yes     No

Does your staff oreintation plan include a review and "walk through" of any disaster plan? Yes     No

How often are evacuations / fire drills conducted each year for each shift?

C. Do all patients have their own attending physicians? Yes     No

If no, who performs the role of attending physician?

D. Are attending physician written orders required for:

All drugs and medicines? Yes     No

Special dietary requirements? Yes     No

Any other specific therapy / treatment? Yes     No

E. All medications kept under locked conditions? Yes     No

F. How often are attending physicians required to update their patient charts?

G. Is a nursing assessment conducted for new patients? Yes     No

If Yes, does this assessment include evaluation of:

Mobility limitations Yes     No

History of prior injuries Yes     No

Required assistance Yes     No

Disorientation Yes     No

H. Do you obtain advance (patient or guardian) written consent that allows your faclity to provide non-emergency medical care when it is needed?	Yes No
I. Please attach details of Restraint Policies and Procedures.
Do you retain (on-site on-call) a physician on a 24-hour basis?	Yes No

K. Who determines if a patient must be transferred to another facility for further non-emergency medical diagnosis or treatment?

L. Is smoking permitted in patient rooms?	Yes No
M. Are there alarms on exit doors to prevent patients from leaving the premises without proper authorization?	Yes No
If No, how is the otherwise controlled?

PART VII - BUILDING AND EQUIPMENT FEATURES

The following information is needed for each building used for patient or resident occupancy. If you have more than one such building you should either complete a copy of this section for each additional building or provide the information in the comments section.

A. Building Identification

	Year Built:
	No. of Stories:

B. Was the building originally designed and constructed for nursing home occupancy?		Yes No
Please advise the type of construction for each building and an estimate of square footage.

If No, what was the original building occupacy?
C. Smoke detectors and automatic sprinkler system / alarms and fire extinquishers.

Location of Smoke Detectors.	Areas protected by approved automatic sprinkler systems.
None	None	Hallways
Hallways	Trash collection area	Commons area
Commons area	Soiled linen areas	Patient or res. rooms
Patient or res. rooms	Cooking areas

Location of alarms or sensors.	Areas supplied with fire extinquishers.
None	None	Hallways
Hallways	Trash collection area	Commons area
Commons area	Soiled linen areas	Patient or res. rooms
Patient or res. rooms	Cooking areas

D. When was this building electric, heating or plumbing systems last inspected or updated?

	ELECTRIC	HEATING	PLUMBING
Qualified Inspection
Replaced or Updated

Advise age and type of heating and wiring systems.

E. When was this building last inspected by the:
Local fire authorities:	Month/Year
State Dept. of Health:	Month/Year

Were any recommendations made.	Yes No
Have you complied with Recommendations.	Yes No
What recommendations were made, if any:

F. Are there at least two exits located remotely from each other, on each floor and fire section?	Yes No
G. Do you have any auxillary electrical system?	Yes No

If no, describe the type and location of any other emergency lighting system in this building.

H. Are handrails provided in hallways and bathrooms?	Yes No
I. Are bathtubs / showers equipped with nonslip surfaces?	Yes No
J. Are all skilled or intermediate care patients beds equipped with siderails?	Yes No
K. Are you planning any new construction for the next tweve months?	Yes No
If yes, use the comment section to describe the purpose, estimated cost and estimated completion date for the construction.
PART VIII - CURRENT COVERAGE AND LOSS HISTORY
A. Current professional / general liability coverage:

Present Insurance Company:	Policy Period:
Limit(s)	Is present coverage:
Deductible(s)	Occurrence
Current Premium	Claims-Made	(Retroactive Date)

B. Losses - describe each professional or general liability claim or circumstance made or brought against your facility during the last five years. (Use Section IX, Comments for an explanation to your attached loss runs).

If a current loss summary is available (from a present or previous carrier), please attach a copy and provide the following information:
a. Date of the event and the date of the claim was reported to the Insurance company.
b. Brief description of the cause of the loss or claim
c. Current status of the claim (open or closed).
d. The paid amount and current oustanding reserve amount.
e. Policy year which claim applies.
f. Aggregate Summary per year.

Signing this application does not bind the Company to complete the insurance. All information requested in this application is considered material and important. If the Company agrees to be bound under the terms of this application your policy is void if your hide any important information from us, mislead us, or attempt to defraud or lie to us about any matter contained in this application.

PART IX - COMMENT SECTION