Hospice Operations Insurance Questionnaire

Hospice Operations Insurance Questionnaire
Applicant's Name:*
Address:*
Mailing Address
Address (cont):*
Mailing Address - continued
Contact:*
Email*
Telephone:*
Website
Fax:
Applicant is:

IndividualPartnershipCorporationOther (specify)Other
Current Carrier:
Expiration Date:
Limits: ($)
Premium: ($)
Deductible: ($)
GENERAL INFORMATION
1. Location of premise:

Same as above mailing address
1a. If different from mailing address above, please list location(s) below or on separate page.
2. Number of years under current ownership:

3. Please indicate the percent of operations for each classification:

Rows	Percentage
Hospice – In-patient facility
Hospice – Out-patient facility
Home Health Care (not Hospice)
Palliative Care (not Hospice)
All other operations (describe below)

3a. Please describe "Other Operations":
4. In the past three years, have any complaints been filed with a Licensing Board against the facility or operations; or has the operating license been revoked, suspended or put on probation?

YesNo
4a. If yes, please explain:
5. Please provide:

A copy of all license(s) issuedA copy of the most recent state health inspectionCorrective measures (if applicable) from the licensure
DESCRIPTION OF OPERATIONS
1. What is the average monthly number of clients (include inpatient and outpatient) being served for hospice?
2. Does the Medical Director provide physician care to residents or patients?

YesNo
2a. If yes, is the Medical Director an independent contractor?

YesNo
2b. Does the Medical Director have their own malpractice insurance for hospice clients?

YesNo

Rows	Yes	No
1a. On prospective employees and volunteers?
1b. On existing employees and volunteers?

Rows	Yes	No
4a. Child/Elder Abuse and Molestation?
4b. How to recognize the signs of abuse?
4c. What to do if an individual reports someone molested him/her?