Respite, In-Home Support, Comm. Access Application

Respite, In-Home Support & Community Access Program Pricing

MARCH 2024 - 2025

Premiums:

$399.86 - Includes $11.65 in Surplus Lines Tax

How to File for a Trade Name

Please complete all of the information in the Online Application. Should you have any questions feel free to contact us.

"*" indicates required fields

Step 1 of 3

33%

Section 1: General Information

Are you new to the Care Association?*

I am Renewing

I am New

I am not sure

Full Name:*

Trade Name (If applicable):

Are you an LLC or S-Corp?*

Yes

Home Address*

Street Address City State ZIP Code

Home Phone Number*

Cell Phone Number:

Email Address:

Are you a Family Care Giver?*

Yes

Do you have EMPLOYEES or do you pay anyone to do services for you?*

Yes

This program is for INDIVIDUAL INDEPENDENT CONTRACTORS PROVIDERS only. If you pay someone to work for you, you must contact our office for further clarifications at 303-333-0375.

Do you work for or contract with a Home Health Care Agency or Assisted Living facility for the elderly?*

Yes

If you work for or are contracted with agencies serving the elderly or home health care you are not eligible for this program.

Name of Agency(s) that you are currently under contract with:*

Primary Agency Phone Number*

Section 2: Underwriting Questions

General Information Questions

1. Are the consumers that you provide services for developmentally disabled?*

Yes

All of you consumers must be developmentally disabled. Due to the nature of this answer, this application cannot be processed online.

Check the age groups that you provide services for:

Under 18 years old

Between 18 and 65

65 years old and over

2. Do you provide overnight respite services to developmentally disabled clients?*

Yes

2a. Do you provide overnight respite in your clients home?*

Yes

2b. Do you provide overnight respite to your clients in your home?*

Yes

If you provide overnight respite in your home do you have renters or homeowners insurance?*

Yes

Homeowners or Renters insurance is required in order for you to provide respite services in your home.

3. Do you provide in-home support services to your consumers?*

Yes

3a. Do you provide any skilled medical care?

Yes

If you provide SKILLED MEDICAL CARE you do not qualify for this program. You may contact our office for further clarification.

4. Are you only providing NON-SKILLED medical care, such as routine medications etc.?

Yes

If you provide SKILLED MEDICAL CARE you do not qualify for this program. You may contact our office for further clarification.

5. Do you provide community access or other support services?*

Yes

Check the age groups that you provide services for:

Under 18 years old

Between 18 and 65

65 years old and over

6. Have you authorized the organization or placement agency to initiate a background check on you and anyone 18yrs of age or older living in your home (This is a requirement)?*

Yes

This is a STATE REQUIREMENT. Please notify your agency. criminal background checks on providers are required. You MAY NOT proceed with the application.

7. Within the last 5 years, have you been subject to any form of disciplinary action as a Host Home Provider by a Court, a Community Centered Board, a Service Provider organization or any other placement agency you are contracted with?*

Yes

Please give a brief description of the incident.

Please give a brief description of the disciplinary action that was brought against you:*

8. Have you ever had an allegation of Mistreatment, Abuse, Neglect or Exploitation?*

Yes

Please give a brief description of the incident.

Please give a brief description of the allegation that was brought against you?*

Hidden

8b. Was this allegation substantiated?*

Yes

Please give a brief description of the outcome.

If yes please give a brief description of the outcome:*

9. Have you had a lawsuit filed against you as a Respite Care provider?*

Yes

Please give a brief description of the lawsuit.

If yes please give a brief description of the lawsuit:*

10. Are you aware of any incident in the past which could result in a lawsuit being filed against you?*

Yes

Please give a brief description.

If yes please give a brief description:*

11. Has any insurance company cancelled or non-renewed similar coverage?*

Yes

Please give a brief description of the cancellation and the reason given.

If yes please give a brief description:*

11. Describe any training you have received to qualify as a provider: Check all that apply:

First Aid

CPR

Abuse Neglect Training

Other

THE APPLICANT DECLARES THE ABOVE STATEMENTS AND REPRESENTATIONS ARE TRUE AND CORRECT AND THAT NO FACTS HAVE BEEN SUPPRESSED OR MISSTATED. THE COMPLETION OF THIS APPLICATION DOES NOT BIND THE COMPANY TO SELL NOR THE APPLICANT TO PURCHASE THIS INSURANCE, BUT ANY SUBSEQUENT CONTRACT ISSUED WILL BE IN FULL RELIANCE UPON THE STATEMENTS AND REPEPRESENTATIONS MADE IN THIS APPLICATION AND THIS APPLICATION WILL BE MADE A PART OF THE POLICY.

THE APPLICANT UNDERSTANDS THAT ANY COVERAGE PROVIDED BY THE COMPANY WILL BE PART OF A MASTER INSURANCE PROGRAM WITH A $1,000,000 LIMIT OF LIABILITY PER CLAIM AND A MAXIUMUM POLICY AGGREGATE LIMIT OF $5,000,000 (THEREFORE, IT IS POSSIBLE THAT CLAIMS ASSOCIATED WITH OTHER HOST HOMES MAY PARTIALLY REDUCE OR ENTIRELY ELIMINATE LIMITS OF LIABILITY AVAILABLE TO YOU.

THE POLICY UNDER THIS PROGRAM IS A CLAIMS-MADE POLICY WHICH PROVIDES LIABILITY COVERAGE ONLY IF A CLAIM IS MADE DURING THE POLICY PERIOD OR ANY APPLICABLE EXTENDED REPORTING PERIOD.

THE CONTRACT UNDER THIS PROGRAM IS DELIVERED AS A SURPLUS LINES COVERAGE UNDER THE "NONADMITTED INSURANCE ACT". THE INSURER ISSUING THE CONTRACT IS NOT LICENSED IN COLORADO BUT IS AN ELIGIBLE NON-ADMITTED INSURER. THERE IS NO PROTECTION UNDER THE PROVISION OF THE COLORADO INSURANCE GUARANTY ASSOCIATION ACT.

PLEASE ENTER YOUR FULL NAME:*

**SHOULD YOU RECEIVE AN ERROR MESSAGE AFTER SUBMISSION DUE TO AN ADDRESS OR (AVS) MISMATCH DO NOT continue to resubmit the transaction. Continued resubmission may result in premiums being withdrawn from your bank account multiple times. Contact or office for further assistance. 303-333-0375

Respite Care Insurance*

Price:

Credit Card Processing Fee (2%)

Price: $0.00

Total

Billing Address of the Credit Card*

Street Address Address Line 2 City State ZIP Code

Cardholder Email

If you have no email address, you will not receive an email confirmation of payment.

Cardholder Phone*

Credit Card*

Discover

MasterCard

Visa

Supported Credit Cards: Discover, MasterCard, Visa

Card Number

Expiration Date Month Year

Security Code Name of the Credit Card Holder

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