The CARE Association

Respite Care, In-Home Support, Community Access & Support Services Online Application Step 1: Fill-out Application Section 1: IF YOU RECEIVE AN ERROR MESSAGE, YOU MUST CONTACT US
* = Required
(IF YOU ARE A HOST HOME PROVIDER, PLEASE CLICK HERE)
Are you new to the program? yes no
Have you been insured during the prior years?	yes no

Full Name (Do not put in your consumer(s) name)*:

Trade Name (If applicable):

Mailing Address*:

City*:

State*:

Zip*:

Email Address:

Agency Placing Consumers*:

Agency Phone Number*:

Phone Number:

Cell Phone Number:

Section 2: Underwriting Questions

1	Do you provide overnight respite serves to developmentally disabled individuals? If yes, answer the following questions:			yes	no

		Do you provide overnight respite in your DD clients home?		yes	no
		Do you provide overnight respite in your home?		yes	no
			If yes, do you have home owners or renters insurance?	yes	no
		Do you provide these services for individuals UNDER 18 years of Age?		yes	no
		Do you provide these services for individuals OVER 65 years of Age?		yes	no

2	Do you provide in home support to a DD individual(s) in their home?			yes	no

		If yes, is the in-home support non-medical?		yes	no
		Do you provide these services for individuals UNDER 18 years of Age?		yes	no
		Do you provide these services for individuals OVER 65 years of Age?		yes	no

3	Do you provide community access or other support services in the community?			yes	no

		Do you provide these services for individuals UNDER 18 years of Age?		yes	no
		Do you provide these services for individuals OVER 65 years of Age?		yes	no

4	How many years of experience have you had as a care provider for individuals with special needs:

5	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

6	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

7	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

8	Have you had a law suit filed against you as a Host Home Provider?			yes	no

9	Are you aware of any incident in the past which could result in a claim being filed against you?			yes	no

10	Has any insurance company cancelled or non-renewed you for similar coverage?			yes	no

11	PLEASE EXPLAIN ANY YES ANSWERS:

12	Describe your training (Ex: CPR, First Aid, Abuse & Neglect, 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.

FURTHERMORE, 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 (Effective 3/1/2012 – 3/1/2013). THEREFORE, IT IS POSSIBLE THAT CLAIMS ASSOCIATED WITH OTHER CARE PROVIDERS 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 INSURANCE 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:

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