The CARE Association

Therapist & Counselor 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

Name*:

Trade Name:

Address*:

City*:

State*:

Zip*:

Email Address*:

Phone*:

Please List Any Additional Office Locations:

Section 2: Underwriter General Information Questions

PROFESSIONAL LIABILITY SECTION CHECK ALL THAT APPLY
BEHAVIOR THERAPIST	REHABILITATION COUNSELOR
SPECIAL EDUCATION SPECIALIST	EARLY INTERVENTION SPECIALIST
OCCUPATIONAL THERAPIST	MUSIC THERAPIST
COGNITIVE THERAPIST	ART THERAPIST
SPEECH THERAPIST	OTHER:

Do you currently have Professional Liability/Malpractice coverage(s) in place? If yes:		yes	no

	Carrier:
	Limit:
	Coverage Dates:

Are you currently licensed and/or certified and in good standing in the state for the professions listed above.		yes	no

Section 3: Underwriter Questions

1	Have you ever been expelled from a professional association or been convicted of a felony?	yes	no
	If yes, please explain:

2	Has Professional Malpractice ever been alleged against you?	yes	no
	If yes, please explain:

3	Are you currently contracted with a Community Centered Board, Service Provider Organization or other placement agency?	yes	no

4	Approximate annual revenues attributable to your professional services:

5	Have you ever been refused coverage for professional liability or malpractice or has your malpractice or professional liability insurance ever been cancelled or declined for renewal (non-renewal)?	yes	no

6	Has any claim or suit ever been brought against you for alleged malpractice or professional liability, or are you aware of any incident or existing circumstances that might reasonably lead to a claim or a suit?	yes	no

7	Have you ever been convicted of a misdemeanor or felony?	yes	no

8	Have you ever had your license, certification or registration suspended, revoked, or placed on probation by a licensing board of examiners, or any other governmental entity that regulates your profession?	yes	no

9	Have you ever received a citation or paid a fine as a result of a board proceeding?	yes	no

10	Have you ever surrendered, either voluntarily or otherwise, your license, certification, or registration?	yes	no

11	Have you ever been accused of sexual misconduct or any professional impropriety?	yes	no

12	Have any complaints ever been filed against you with a peer review committee or an ethics committee, a professional association, hospital, health care facility, licensing board, or any other governmental or a private entity?	yes	no

13	Do you know of any reason why you cannot comply with the legal, ethical, or professional standards set forth by law, by regulation, by a peer review committee or by an applicable code of ethics in any jurisdiction where you provide services?	yes	no
PLEASE EXPLAIN ANY YES ANSWERS:

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. 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 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