Home Health Care Services Questionnaire

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Home Health Care Services Questionnaire

Home Health Care Services (Companion Care 245D)

We work with over 40 carriers offering business insurance programs and many additional brokers giving us access to hundreds of more carriers.

The questionnaire is extensive and includes many questions to find as many discounts and affinity programs as possible to fine the best fit.

A group of business people standing around a puzzle piece.

Companion Care

Companion Care

"*" indicates required fields

Step 1 of 10

10%

Business Name (if no Business name, use Personal Full Name)*

What is Business Type (Contractor, Store, Inspector, etc.)*

Years of Experience in Trade

New Venture

1 Years

2 Years

3 Years

4 Years

5 Years

6 or More Years

Owner Name*

First Last

Primary Contact Phone*

Primary Contact 2nd Phone

Cell Phone

Primary Business Phone

Owner Email*

Owner 2nd Email

Your Company Website

Your Prior/Current Insurance Information (Insurance Company, renewal date, Coverages)

Address(es)

Mailing Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Is the premises address the same as the Mailing Address

Yes, the same address

No

Premises Address (If different than mailing)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Business Information

In Business Since (Year)

Type of Insurance Needed (General Liability, Workers Comp, Property, etc.)

General Liability

Professional Liability

Workers Compensation

Physical & Sexual Abuse Coverage

Abuse & Molestation Coverage

Auto Liability

Bond - Fidelity

Business Auto

Cyber Liability

Equipment Coverage

Hired and Non-Owned Auto Liability (HNOA)

Property Insurance

Umbrella - Commercial

Business Entity (Individual, LLC, S-Corp, C-Corp, Non-Profit)

LLC

Individual

S-Corporation

C-Corporation

Non-Profit) (503-C)

Federal Tax ID (Use Social Security Number if none assigned by Government)

State Unemployment ID Number (if known)

Number of Owners

1

2

3

4

5 or More

Number of Full-Time Employees (Not including Owners)

0

1

2

3

4

5

6

7

8

9

10 or more

Number of Part-Time Employees (Not including Owners)

0

1

2

3

4

5

6

7

8

9

10 or more

Amount Paid to Subcontractors annually

Estimated Revenue (Next 12 Months)

Revenue (Last 12 Months)

Estimated Total Annual Payroll (excluding Owners)

Total Annual Payroll Last 12 Months (excluding Owners)

Amount of Equipment Coverage Needed

Owner Information

Primary Owner First and Last Name

First Last

Primary Owner Date of Birth

MM slash DD slash YYYY

Primary Owner Driver's License Number

Primary Owner Social Security Number

Primary Owner's highest level of education obtained (Discounts Available)

Additional Owners Information (Names, Contact Info)

Want to complete full application (Yes, for fully underwriting, No- Quick Quote)

No, Just a quick quote

Yes, I want to complete entire application to have underwriting approve)

Home Health Care Underwriting Information

Is your business operated out of your home

Yes

No

How many additional locations does your business own or rent

0

1

2

3

4 or More

Businesses that supply, manufacture, or distribute any tangible goods or products

Yes

No

Properly trained or certified to provide medications to patients

Yes

No

What is the most common age group that you treat

Mostly over 65 Years Old

Under 18 years old

Mostly between 18 to 65 years old

Does your business use a written consent form

Yes

No

The firm maintains current and valid professional training, certifications, licenses

Yes

No

Investigated by the State Health Dept., State Licensing Board

Yes

No

Is the applicant’s operation Medicare-approved

Yes

No

Amount of Medicare sales

Do employed nurses have their own Professional Liability coverage?

Yes

No

Require Certificates of Insurance from (RNs, LPNs) independent contractors

Yes

No

Are employees required to complete daily work reports

Yes

No

Does the applicant conduct patient/client surveys

Yes

No

Percentage of Clients Under 18 Years of Age

Percentage of Clients over 65 years of age

Is 24 Hour Service provided (Yes, No)

Yes

No

If so, Percent of Operations

If so, is this Live In (Yes, No)

Yes

No

If so, Shift Work (Yes, No)

Yes

No

Home Health Care Underwriting Information Continued

Please describe the services performed by any other professionals

Please provide details of the license or certification needed for operation

Please describe the services performed by any other professionals

Does the applicant sell or rent equipment to clients

Yes

No

What state/s are you licensed or certified in

Been investigated by the State Health Dept., State Licensing Board

Yes

No

Accredited by the National Association of Home Care

Yes

No

Accredited by the Joint Commission on Accreditation of Healthcare Organizations

Yes

No

Accredited by the Joint Commission on Accreditation of Healthcare Organizations

Yes

No

Sales from independent contractors

Sales from non-nursing operations

Do employed nurses have their own Professional Liability coverage

Yes

No

If so, Limits Required

Require Certificates of Insurance from all nursing independent contractors

Yes

No

If so, Limits Required

Employees/independent contractors responsible for monitoring equipment

Yes

No

If so, Full Description

Utilize a formal Quality Assurance/Risk Management program

Yes

No

Is there an informed consent process in place

Yes

No

Services Provided

Do you or your employees perform Catheterization (other than urinary or umbilical)

Yes

No

Do you or your employees perform Diagnosing conditions, disorders, or diseases

Yes

No

Do you or your employees perform Holistic medicine

Yes

No

Do you or your employees perform Injections of any kind

Yes

No

Do you or your employees perform Infusion therapy

Yes

No

Do you or your employees perform Laser treatments

Yes

No

Do you or your employees perform Medical marijuana dispensing

Yes

No

Do you or your employees perform Organ/sperm/blood services

Yes

No

Do you or your employees perform Patient transportation

Yes

No

Do you or your employees perform Patient or client care at Your facility or residence

Yes

No

Do you or your employees perform Physical therapy

Yes

No

Do you or your employees perform Research or experimental services

Yes

No

Do you or your employees perform Healthcare or home health aide staffing

Yes

No

Do you or your employees perform Stress test services

Yes

No

Professionals Information

Are you or any of your employees an active Medical Doctor

Yes

No

Are you or any of your employees an active Medical Doctor

Yes

No

Are you or any of your employees an active Midwife

Yes

No

Are you or any of your employees an active Nurse Practitioner

Yes

No

Are you or any of your employees an active Physician’s Assistant

Yes

No

Are you or any of your employees an active Registered Nurse

Yes

No

Are you or any of your employees an active Naturopathic doctor

Yes

No

Personnel Information

Aides/Homemaker Health Aides Number Employed

Aides/Homemaker Health Aides Number Contracted

Aides/Homemaker Health Aides Contractors Ins. Limits Required

Aides/Homemaker Health Aides Percent Hospital Work

Aides/Homemaker Health Aides Percent Nursing Home Work

Aides/Homemaker Health Aides Percent Home Work

LPNs Number Employed

LPNs Number Contracted

LPN’s Contractors Ins. Limits Required

LPNs’ Percent Hospital Work

LPNs’ Percent Nursing Home Work

LPNs’ Percent Home Work

RN’s Number Employed

RN’s Number Contracted

RN’s Contractors Ins. Limits Required

RN’s Percent Hospital Work

RN’s Percent Nursing Home Work

RN’s Percent Home Work

Home Companions Number Employed

Home Companions Number Contracted

Home Companions Contractors Ins. Limits Required

Home Companions Percent Hospital Work

Home Companions Percent Nursing Home Work

Home Companions Percent Home Work

Certified Nursing Assistants Number Employed

Certified Nursing Assistants Number Contracted

Certified Nursing Assistants Contractors Ins. Limits Required

Certified Nursing Assistants Percent Hospital Work

Certified Nursing Assistants Percent Nursing Home Work

Certified Nursing Assistants Percent Home Work

Others (Not already specified) Description

Other Number Employed

Other Number Contracted

Others Contractors Ins. Limits Required

Others Percent Hospital Work

Others Percent Nursing Home Work

Others Percent Home Work

Misc

Note, Questions and Concerns

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