Certified Homecare Consulting Insurance Application

  • Certified Homecare Consulting

    Insurance Program Application
  • Format: (000) 000-0000.
  • Are you a start-up?
  • Is your company licensed to do business is the states listed above (where required)?
  • Has any Professional or General Liability claim or suit been brought in the past five years against applicant or any predecessor in interest concerning the entity to be insured, or are you aware of suits, or any incident that could become a claim or suit, that have occurred?
  • Do you provide overnight beds or residential services?
  • Do you provide treatment or services on your own premises?
  • Do you accept transportation-only clients?

  • Non-Owned Auto

    (We Strongly Recommend Non-Owned Auto. It is our #1 Category for Claims Dollars Paid)
  • Do you verify personal auto insurance for driving employees of at least state-minimum limits?
  • Do you require driving employees to carry higher than state minimum personal auto liability limits? No one does, so question is defaulted to 'no'.
  • How often are employee's autos or client's autos used in your business? We assume daily, but please change below if necessary.
  • Do you order MVRs annually for all employees and volunteers driving their own vehicles (or a client's vehicle) for business purposes?
  • By signing this application, you warrant that only those drivers that meet the following conditions will be allowed to drive on company business: 1) No more than two moving violations within the past three years; 2) No at-fault accidents within the past three years; and 3) No convictions for DUI/DWI, reckless driving, vehicular manslaughter, driving dangerously or similar.

  • This insurance does not apply to any of the following: physician, surgeon, dentist, physician's assistant, nurse practitioner, nurse midwife, chiropractor, podiatrist, osteopath, or psychiatrist. Unless otherwise provided by endorsement, these medical professional occupations are excluded from coverage. The insurance described herein is subject to all terms, conditions and exclusions of the insurance certificate.

    Applicant’s Warranty Statement: The undersigned represents to the best of his/her knowledge and belief the particulars and statements set forth are true and agree that those particulars and statements are material to the acceptance of the risk assumed by the Company. The undersigned further declares that any claim, incident or event taking place prior to the effective date of the insurance applied for which may render inaccurate, untrue, or incomplete any statement made will immediately be reported in writing to the Company and the Company may withdraw or modify and outstanding quotations and/or authorization or agreement to bind the insurance. The signing of the Application does not bind the undersigned to purchase the insurance, nor does the review of the Application bind the Company to issue a policy. It is understood the Company is relying on the Application in the event th Policy is issued. It is agreed that this Application, including any material submitted therewith, shall be the basis of the contract should a policy be issued, and may be attached to and become part of the policy.


    Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing false information, or conceals, for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act.

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