Phone:

804-359-4568

Toll Free:

800-396-6226

Fax:

804-359-6994

E-Mail:

info@commund.com

Home Health Care Agencies Online Quote

Please complete the following and press submit or call 800-396-6226 x202 for an instant phone quote

Agent Information
Commonwealth Underwriters Agent Code: *Note: this field is optional*

Agency Name:
Agent Name:
first and last name
Phone:
999-999-9999 format
Agent Email:
(A copy of the quote will be sent to this address)
Insured Information
Insured Name:
Insured Email: (will only be used to communicate regarding this account)
Insured's Mailing Address
Insured Zip
Is Location Address same as Mailing Address? (Click if Yes)
Location Address
Location Zip
Would you like a finance quote? (Click if Yes)
Agency's Mailing Address
Agency City
Agency State
Agency Zip
Classification (Receipts)
Home Health Care Services -- 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)
Years of Experience
Limit Required
Is This a New Venture?
Any Infusion Therapy? (Click if Yes)
Any Contracted or Employed Physicians or Physicians Assistants? (Click if Yes)
Any Contracted or Employed Nurse Practitioners? (Click if Yes)
Any Contracted or Employed Birth or Postpartum Doulas? (Click if Yes)
Any Contracted or Employed Midwives? (Click if Yes)
Any Contracted or Employed Personal Trainers? (Click if Yes)
Any Uninsured Independent Contractors Performing Medical or Professional Care? (Click if Yes)
Any Service Provided to Clinics, Hospitals, Physician's Offices, Convalescent / Nursing Homes, Assisted Living Facilities, Hospices, Jails, Prisons, or Detention Centers? (Click if Yes)
Is the Insured hired by the Patient or Patient's Guardian directly for this service?
Does insured own and operate a pharmacy? (Click if Yes)
Does insured perform foster care placement? (Click if Yes)
Does insured perform any care in owned, leased, or rented premises? (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)
What type of additional insureds are needed?
Is Blanket Additional Insured Coverage needed?
How many additional insureds are needed?
How many additional insureds are needed?
Does insured hire subcontractors? (Click if Yes)
What percent of workers hired are subcontracted? %
Are subcontractors paid by the clients directly rather than the insured?
Total subcontractor Payroll/Cost to insured (in dollars): $
Any Transportation Provided for Patients? (Click if Yes)
Does the insured confirm that personal auto coverage is in place? (Click if Yes)
Will insured need Terrorism Coverage?
Commission
What commission would you like for this account?
Additional Comments
Additional Comments:



For higher limits or coverage options not listed, please contact Heather Jones, Ext 121.

Any questions or problems with the form? Please contact Heather Jones



Only Commonwealth Underwriters, Ltd. has binding authority. Coverage will not be bound until application has been received, reviewed, and accepted by Commonwealth Underwriters, Ltd.