This application must be completed in conjunction with the Allied Healthcare Facility Common Application

INSTRUCTIONS

1. Please read the instructions carefully. Complete and submit all requested information and/or required attachments. This application and all materials submitted shall be held in confidence.

2. All application questions must be fully answered. If a question does not apply, please write “N/A”.

3. If you need more space, continue on a separate sheet of your letterhead and indicate the question number.

1. Name of Applicant: _______________________________________________________________________________________

2. Services

A. What surgical specialties/procedures are provided at the facility(s)? If services cross specialties, do not duplicate numbers. Assign to one specialty.Please provide information by state.

Selected State: _____________

Services % # of Procedures Annual Projection

Abortions

Bariatric (see breakout below)

– Laparoscopic Gastric Bypass, including Rouex-en-Y Gastric Bypass

– Adjustable Gastric Band, including LAP-BAND®

– General Surgery approach Gastric Bypass

– Distal Gastric Bypass

– Billiopancreatic Diversion

– Gastroplasty

– Gastric Sleeve

– Other (please describe)

Birthing Centers

Cardiac

– Catheterization/Angioplasty

– Cardiac Pacing

– Implantable Cardioverter-defibrillator, Lead, Pacemaker

Dental oral and Maxillofacial

Endoscopy/Colonoscopy

ENT/Otorhinolaryngology

Gastrointestinal/GI

General Surgery

Gynecological Surgery

Imaging - venography, fluoroscopy, & ultrasonic needle guidance

In vitro fertilization

Lithotripsy

S U P P L E M E N T A L A P P L I C A T I O N

Ambulatory Surgery Centers

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Services % # of Procedures Annual Projection

Neuro (including Gamma knife)

Ophthalmology

– LASIK

– Non-LASIK

Orthopedic

Pain management

– Anthroplasty including-facetectomy, laminectomy, foraminotomy

– Discectomy & Micro-discectomy

– Vertebral column fixation/spinal fusion (non-instrumented)

– Sacroplasty

– Other (please describe)

Plastic Surgery Cosmetic and Reconstructive Surgery

– Cosmetic

– Reconstructive

Podiatric

Radiation oncology/therapy/chemotherapy

Thoracic

Urologic

Vascular

Other (Please Describe)

Total

B. Overnight Recovery Beds Yes No

C. If the stays are longer than 24 hours, how many beds? ______

D. Patient Selection

1. Based on the ASA Physical Status Classification System, what percentage of patients are accepted annually?

P1 A normal healthy patient

P2 A patient with mild systemic disease

P3 A patient with severe systemic disease

P4 A patient with severe systemic disease that is a constant threat to life

P5 A moribund patient who is not expected to survive without the operation

P6 A declared brain-dead patient whose organs are being removed for donor purposes

2. Do you treat professional athletes or celebrities? Yes No

3. ACCREDITATIONS AND LICENSURE (Provide dates of certification. If not applicable select “N/A”)

A. Licensure/Accreditations/Special Awards/Center of Excellence

Date of Expiration N/A

State Licensure

Medicare Certification

AAAASF – Amer. Assoc. for Accreditation of Ambulatory Surgery Facilities

AAAHC – Accreditation Association for Ambulatory Health Care, Inc.

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Date of Expiration N/A

HFAP – American Osteopathic. Association, Healthcare Facilities

Accreditation Program

Institute for Medical Quality (IMQ)

TJC The Joint Commission

Other: (Please Describe)

B. Were any deficiencies cited in the most recent surveys? Yes No

C. If this is a new operation, will accreditation be sought within the next 12 months? N/A Yes No

4. EMPLOYEES/INDEPENDENT CONTRACTORS INFORMATION

A. Licensed/Non-Licensed

Licensed Number Full-Time

Number Part-Time

Annual Payroll Number of 1099’s

Advanced Practice Nurses/ Nurse Practitioners/ Midwives

Certified Medical Assistants

Certified Nurse Assistants

Interns

Nurses (RN, LPN, LVN)

Pharmacists

Physician Assistants/ Surgeon Assistants

Residents

Students

Technicians

Technologists

Therapy Aides/ Assistants

Other: (Please Describe)

B. Does applicant want coverage to include independent contractors? Yes No

C. Does applicant obtain certificates of insurance from independent contractors? Yes No

COMMENTS

Please provide any additional information or requests not reflected in the application

____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

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126-0116 (7/14)

hanover.com

The Hanover Insurance Company | 440 Lincoln Street, Worcester, MA 01653

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AUTHORIZATION

I have answered the questions in the Application to the best of my ability and declare that, to the best of my knowledge, the statements set for the herein are true and correct. My signing of the Application does not bind the Insurance Company to complete the insurance, but it is agreed that this Application shall be the basis of the contract should a policy be issued.

FRAUD NOTICE–Where Applicable Under The Law of Your State

Any person who knowingly and with the intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false or incomplete information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and may be subject to civil fines and criminal Penalties.

For New York Residents only: and shall be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each violation.

For Pennsylvania Residents only: Any person who knowingly and with intent to injure or defraud any insurer files an application or claim containing any false, incomplete or misleading information shall, upon conviction, be subject to imprisonment for up to seven years and payment of a fine of up to $15,000.

For Tennessee Residents only: Penalties include imprisonment, fines and denial of insurance benefits.

SIGNATURE IN FULL: __________________________________________________ DATE: ________________________________

PRINT NAME: ________________________________________________________

ALL QUESTIONS MUST BE ANSWERED AND THE APPLICATION MUST BE SIGNED AND DATED

Agency Name and Address: _____________________________________________________________________________________

Person Submitting Application: __________________________________________________________________________________

Telephone Number: _____________________________ Email: _______________________________________________________