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Host Home Provider
Online Insurance Application
Step 1: Fill-out Application


 

Section 1 (For Host Home Premium Pricing Info, Click Here)
 
* = Required
 
Are you new to the program? yes  
Have you been insured during the prior year and is this application renewing that coverage?* Yes
Full Name (Do not put in your consumer(s) name)*:
Trade Name (If applicable)
Mailing Address*:
City*:
State*:  
Zip Code*:
Email Address:
Home Phone*:
Cell Phone Number:
Host Home Address*:
Host Home City*:
Host Home State*:  
Host Home Zip Code*:
     
Name of Agency Placing Consumers in Your Home*:  
Agency Phone Number*:
     
Section 2: Underwriting Questions    
General Information Questions    
1

Has the organization [CCB or SPO] visited your Host Home and will they be making periodic visits to your home (This is a state requirement)?

   yes no
2

Have you authorized the organization [CCB or SPO] to initiate a background check on you and anyone 18yrs of age or older living in your home (This is a state requirement)?

   yes no
3 How many years of experience have you had as a Host Home Provider*?
4 a. Do you own and/ or rent your residence?    yes no
 

b. Do you carry homeowners and / or renters insurance?

   yes no
 

c. Do you rent your residence? 

  yes no
 

d. Do you carry renters insurance?

   yes no
5 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 organization you are contracted with?   yes no
6 Have you ever had an allegation of Mistreatment, Abuse, Neglect or Exploitation?   yes no
  If Yes, did it result in substantiated Mistreatment, Abuse, Neglect or Exploitation?   yes no
7 Have you had a law suit filed against you as a Host Home Provider?   yes no
8 Are you aware of any incident in the past which could result in a law suit being filed against you?   yes no
9 Has any insurance company cancelled or non-renewed similar coverage?   yes no
10 Describe any training and/or certification you have received to qualify as a provider:
  Check all that apply:

First Aid  
CPR  
Abuse Neglect Training  
Other  
11 Is your consumer developmentally disabled*?   yes no
       

Please indicate the number of consumers in each age range:
18 - 64  
65+ *  

* If you have any consumers 65+, the next six questions MUST be answered.

If you have a Client over 65 Years of Age, Please Answer the Following Questions
1

Is your consumer ambulatory? [Can they walk on their own without assistance?]

   yes no
2 Does your consumer require assistance in order to walk all or most of the time?   yes no
3

Is your consumer in a wheelchair all or most of the time?

   yes no
4

Is your consumer confined to a bed?

   yes no
5

Does your consumer require medical or nursing care on a daily basis?

   yes no
6 Can your consumer care for themselves?  If not, what things must you do for your consumer on a daily basis?   yes no
  Check all that apply:

Cook  
Bathe  
Clean  
Administer Medications  
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 REPRESENTATIONS MADE IN THIS APPLICATION AND THIS APPLICATION WILL BE MADE A PART OF THE POLICY. 

FURTHERMORE, THE APPLICANT UNDERSTANDS THAT ANY COVERAGE PROVIDED BY THE COMPANY WILL BE PART OF A HOST HOME INSURANCE PROGRAM WITH A $1,000,000 LIMIT OF LIABILITY PER CLAIM AND A MAXIMUM POLICY AGGREGATE LIMIT OF $5,000,000 (Effective 3/1/2012 - 3/1/2013).  THEREFORE, IT IS POSSIBLE THAT CLAIMS ASSOCIATED WITH OTHER HOST HOMES MAY PARTIALLY REDUCE OR ENTIRELY ELIMINATE LIMITS OF LIABILITY AVAILABLE TO YOU. IT IS AGREED THAT SUCH COVERAGE AS IS AFFORDED BY SECTION 102(1) OF THE TERRORISM RISK ACT OF 2002 IS INCLUDED FOR NO PREMIUM CHARGED.

PLEASE TYPE IN YOUR NAME BELOW.  BY DOING SO, APPLICANT HAS READ AND UNDERSTANDS THE ABOVE INFORMATION AND REALIZES THERE WILL BE NO CANCELLATION REFUNDS.

PLEASE ENTER YOUR FULL NAME: 


 


* PLEASE NOTE: UPON SECURING PAYMENT ONLINE, YOU MUST RECEIVE A CONFIRMATION NUMBER FOR APPLICATION PROCESS TO BE COMPLETE.

 

 



The CARE Association
CenterPoint Insurance Group
Michael R. Simms/President-Owner

3900 E. Mexico Avenue, Suite 850

Denver, Colorado 80210
303-333-0375
 

 Last Updated 08/04/2011
 

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