| Classification (Receipts) |
Home Health Care Serves -- 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) |
|
| Limit Required |
|
| Sexual Abuse Sublimit - Limit cannot exceed GL limit above |
|
| Any Infusion Therapy? |
(Click if Yes) |
| Any Hired or Non-Owned Auto Liability? |
(Click if Yes) |
| Any Contracted or Employed Physicians? |
(Click if Yes) |
| Any Service Provided to Clinics, Hospitals, Physician's Offices, Convalescent / Nursing Homes, Assisted Living Facilities or Hospices? |
(Click if Yes) |
| Is Agency Owned or Operated by Physicians? |
(Click if Yes) |
| Any Jail or Detention Centers? |
(Click if Yes) |
| Any Health Care Case Management? |
(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 Additional Insureds? |
(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) |
