instructions - hanover insurancethis application must be completed in conjunction with the allied...
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This application must be completed in conjunction with the Allied Healthcare Facilities 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. Type of Facility (check all that apply):
Free Standing Provider Based (unit of hospital, nursing home, or home health agency)
Critical Access Hospital Based Other: List _____________________________________________________________
3. What population do you service (%)?
Elderly ______% School Based ______% Migrant ______% Homeless ______%
Other ______% (Describe) _______________________________________________________________________________
4. Current Number of Patients: ______
a. Typical % of pediatric patients ______%
b. Typical % of adult patients ______%
5. Is the Applicant deemed under the Federal Tort Claims Act? Yes No
If So, please provide the following:
a. A copy of the most recent FTCA application for Medical/Dental Professional Liability
Protection. Form 5 Parts A-C, Original Deeming Letter, and Uniform Data System
(UDS) Report.
b. FTCA initial deeming date: __________ Deeming end date: __________
c. Are any sites at which services are provided operated by a sub-recipient or contractor? Yes No
i. If Yes, are all deemed services and deemed locations? Yes No
ii. If Not, please explain: _____________________________________________________________________________
d. Does the Applicant require individuals not covered by the FTCA to carry
Professional Liability Insurance? Yes No
i. If Yes, indicate the minimum professional liability limits required:
$_________________ each claim/ $_________________ aggregate
ii. If No, please complete Roster Addendum
S U P P L E M E N T A L A P P L I C A T I O N
Community Health Center
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e. Do interns/medical residents or others provide primary care rotations at the Applicant’s
health center? Yes No
i. If Yes, is the training covered by the FTCA deeming letter? Yes No
ii. If the training is not covered by the FTCA deeming letter, what entity
is responsible for providing insurance coverage?
Applicant Medical School Other: _______________________________________________________
iii. If training is provided by the applicant, do you want coverage to include
interns/medical residents Yes No
If Yes, please provide the average number of FTEs per week ______
f. Does the Applicant require volunteers to carry Professional Liability Insurance? Yes No
i. If Yes, indicate the minimum professional liability limits required:
$_________________ each claim/ $_________________ aggregate
ii. If No, please complete Roster Addendum
6. Do you arrange with local community providers to provide after-hours coverage
to your patients? Yes No
a. If Yes, is this arrangement approved within Scope? Yes No
b. If the arrangement is not approved within Scope, do you require the other entity
and providers to maintain insurance? Yes No
7. Indicate % of Gross Receipts by Type of Care and Visits. “Visits” are defined as the number of patients entering the
facility for health related services per year.
Services Provided % of Gross Receipts
Projected Annual Number of Deemed
Visits/Revenue as noted
Projected Annual Number of
Non-deemed Visits/Revenue as noted
Adult Primary Health Care # of visits – # of visits –
Behavioral Health — indicate number of visits in sections below
Substance Abuse Counseling # of visits – # of visits –
Mental Health Counseling # of visits – # of visits –
Chronic Disease Management, e.g. asthma, obesity, diabetes # of visits – # of visits –
Clinical Trials Revenues: Revenues:
Dental Care # of visits – # of visits –
Emergency/Urgent Care # of visits – # of visits –
Eye Care # of visits – # of visits –
Food Bank/Meals # of meals – # of meals –
Health Fair — Adult Immunizations # of visits – # of visits –
Home Health Care # of visits – # of visits –
Imaging Services Revenues: Revenues:
Immunizations, including tetanus, diphtheria, and influenza # of visits – # of visits –
Insurance Eligibility Screening # of visits – # of visits –
Invasive Procedures (please describe) # of visits – # of visits –
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Services Provided % of Gross Receipts
Projected Annual Number of Deemed
Visits/Revenue as noted
Projected Annual Number of
Non-deemed Visits/Revenue as noted
Laboratory Testing Revenues: Revenues:
Medical Referral Services # of visits – # of visits –
Medical Social Services # of visits – # of visits –
Methadone Dispensing # of visits – # of visits –
Nutritional Counseling # of visits – # of visits –
Pediatric Primary Care # of visits – # of visits –
Pharmacy Revenues: Revenues:
Pre-employment physical exams # of visits – # of visits –
Social Services # of visits – # of visits –
TB Testing # of visits – # of visits –
Women’s Health Care — Indicate by sections below
Abortions # of visits – # of visits –
Breast examination # of visits – # of visits –
Dilatation and Curettage # of visits – # of visits –
Family planning services # of visits – # of visits –
Mammography Referral # of visits – # of visits –
Obstetrical Deliveries # of visits – # of visits –
Post-partum care # of visits – # of visits –
Prenatal care # of visits – # of visits –
Other: # of visits – # of visits –
8. Staffing:
Personnel by category Employees/
Contractors
working more
than 32.5
hours per week
(DEEMED)
Specialty
Providers (as
defined by the
FTCA) working
less than 32.5
hours per week
(DEEMED)
Employees
(Non-deemed)
Contractors
(Non-deemed)
Volunteers
Medical/Clinical Directors
Family Practice Physicians
Internal Medicine Physicians
OB/GYNs
Pediatricians
Other Specialty Physicians
(please describe)
Physician Assistants
Nurse Practitioners
Certified Nurse Midwives
Pharmacists
Dentists/Oral
126-0117 (6/14)
hanover.com
The Hanover Insurance Company | 440 Lincoln Street, Worcester, MA 01653
PAGE 4
Personnel by category Employees/
Contractors
working more
than 32.5
hours per week
(DEEMED)
Specialty
Providers (as
defined by the
FTCA) working
less than 32.5
hours per week
(DEEMED)
Employees
(Non-deemed)
Contractors
(Non-deemed)
Volunteers
Psychiatrists
Psychologists
Other Licensed Independent
Professionals (please describe)
9. Do you use volunteers? Yes No
If Yes, what type of services do they provide? ________________________________________________________________
If Yes, do all volunteers undergo a criminal background check? Yes No
10. Do you operate a Pharmacy? Yes No
a. If Yes, Receipts $_________________
b. If the Applicant is a distributor are the prescriptions: pre-packaged, or compound mixture
c. Is the Applicant: packaging, compounding, or performing admixture?
d. Does the pharmacy compound medications? Yes No
e. Does the pharmacy dispense controlled narcotics? Yes No
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