CNA Long Term Care Insurance Forms

CNA HealthPro LONG TERM CARE
NEW BUSINESS SUPPLEMENTAL APPLICATION

This application must be completed and signed by the applicant. In addition, the following must be attached to the application.

The following are required for all levels of care:

• Accord Applications: Property Auto General Liability Crime Inland Marine Electronic Data Processing Umbrella

• Signed Statement of Values

• LTC Business Interruption Worksheet (if applicable)

• Current valued loss reports of prior carriers

• Current audited financial statement (income, balance sheet, cash flow) with management notes

• Photo and facility diagram/plot plan

• Brochures and/or advertising materials

• Facility web site URL

The following are required for Subacute/Skilled/Intermediate/Assisted Living Facilities:

• Resumes for Administrator & Director of Nursing (DON)

• Copy of facility license

• State survey reports - last 2 years (Include all statements of deficiencies and Corrective Action Plans)

• Substantiated Complaint Survey(s) and Corrective Action Plans if complaint is within the last 2 years

The following are required for Subacute/Skilled Nursing Facility/Intermediate Care Facilities:

• Current CMS Forms 671 Facility Staffing & 672 Resident Census

• Copy of facility’s Skin/Wound Protocol

• Quality Indicator Reports for the past two, six-month periods

I. Corporate/Parent Information

1. Corporate/Parent Name:

Corporate Address:

City: State: Zip Code:

2. Description of Corporate/Parent (check all that apply):

For-Profit Not-for-Profit Individual Partnership Corporation Hospital Affiliated CCRC

JCAHO Accredited CCAC Accredited

3. Years parent company has been under present ownership:

4. Total number of facilities owned:

5. Is the parent company managed by a management company? Yes No

If “Yes,” provide the name of management company:

How many years has a contract been in place with this management company?

Provide a copy of the management contract.

6. List the Officers of the Operating Corporation or General Partners:

II. Applicant/Facility Information

7. Facility Name:

Facility Address:

City: State: Zip Code:

Federal Employer ID #: Provider ID #:

Contact Name: Telephone:

Email Address: Fax:

8. In the past three (3) years, has any insurance carrier cancelled or refused coverage that is similar to the coverage being applied for here? Yes No

If “Yes,” explain:

9. In the past five (5) years, has any claim or suit been made against you for alleged medical professional malpractice, error or mistake? Yes No

If “Yes,” explain. Attach list with comments.

10. How many years has the facility been under: Present ownership? Present management?

11. Are all applicable permits up to date? Yes No

If “No,” explain:

III. Subsidiaries

12. List all subsidiaries. Additional list attached? Yes No

Name / Location / Description of Operations

IV. Facility Credentials

13. List facility information below:

a. License and Accreditation Information:

b. Association memberships:

c. Date of last inspection/survey:

d. Number of deficiencies: Total: D, E, F, G deficiencies: F, H, I, J, K, L deficiencies:

e. Was a Corrective Action Plan accepted by the State? Yes No

f. How many complaints were investigated in the past three (3) years?

How many complaints were substantiated?

g. Is facility approved for Medicare? Yes No If “Yes,” # of beds:

Is facility approved for Medicaid? Yes No If “Yes,” # of beds:

V. Classification

14. Select only the level of care reflected in the facility license. If the license is not specific with respect to type of care, select the one level that best reflects the primary medical services provided by this facility. Please indicate total licensed beds (If Independent Care, skip to “Independent Care” section).

Sub Acute:

Ventilator care, wound management, post operative/trauma recovery, intravenous antibiotic and/or hydration therapy, spinal cord/head injury, oncology, total parenteral nutrition (TPN), blood plasma transfusion, central line care, tracheotomy, dialysis

Total Licensed Beds: Average Occupancy:

Skilled Nursing:

Administration of medication by injection, catheter insertion and sterile irrigation, physical and occupational therapy, administration of oxygen and inhalation therapy, routine changing of dressings, tube feeding, Alzheimer’s care and services

Total Licensed Beds: Average Occupancy:

Intermediate Care:

Administration of oral medications, assistance with Activities of Daily Living (ADLs), preventive turning/positioning, restorative rehabilitation

Total Licensed Beds: Average Occupancy:

Assisted Living:

Combination of housing, personalized supportive services, health care services designed for persons who are mostly able to care for themselves. Provides protective environment, meals, assistance with medications, group socials and spiritual activities, etc.

Total Licensed Beds: Average Occupancy:

Personal Care:

Combination of housing, personalized supportive services, health care services designed for persons who are mostly able to care for themselves. Provides protective environment, meals, assistance with medications, group socials and spiritual activities, etc.

Total Licensed Beds: Average Occupancy:

Independent Care:

Residents of retirement age, total self care, live self-sufficiently, occupy apartment/dwelling units including cooking facilities, do not receive health care services, administer own medications without assistance, full time caretaker on premises.

a. What is the total numbers of units?

b. What is the total numbers of residents at full occupancy?

c. Are there common dining facilities? Yes No

d. Do individual units have cooking appliances (excluding microwaves)? Yes No If “Yes,” check type: Gas Electric

e. Is there a daily mechanism to keep track of residents? Yes No If “Yes,” explain procedure:

f. Are residents allowed to have home health care aides?

g. Are the aides contracted independently? Yes No Through facility? Yes No

h. Are there licensed nursing personnel on staff? Yes No

What hours are they available? What services do they provide?

Home and Community Based Services:

Handyman services, durable medical equipment, homemaker, home care aids, hospice care, rehabilitation therapy, respiratory services, oxygen supplier, prosthetic/orthotic services, skilled nursing care

Number of visits: Receipts:

Attach a description of operations.

Adult Day Care:

Social (80911) Total Participants:

Enhanced (Mentally Challenged) (80912) Total Participants:

Social – Services include but not limited to recreational activities (crafts, music, games, shopping trips), intergenerational programs, promotion of wellness and socialization programs, educational programs

Medical – Services include but not limited to/for the same as social, yet will also include additional services such as medication supervision, medical, nursing, nutritional and therapy services, disabled and rehabilitation services, counseling services, Physical Therapy (PT), speech and Occupational Therapy (OT). Provided service includes service for the mentally challenged, cognitively impaired, developmentally disabled, and chronically ill.

15. Show the percentage of residents by age range:

< 30 = 30-64 = 65-74 = 75-84 = 85-94 = >94 =

16. If any residents are under 64, please explain:

17. Additional general liability exposures.

a. Swimming Pools

(i) Is there a swimming pool? (80901) Yes No

(ii) Is it open to the public? Yes No

(iii) Is the pool locked when not in use? Yes No

(iv) Is the pool fenced? Yes No

(v) Is a full-time lifeguard on duty? Yes No

(vi) Is there a diving board/sliding board? Yes No

(vii) Are there depth markings? Yes No

(viii) Is there a daily maintenance procedure in place? Yes No

b. Are there other bodies of water present? Yes No

If “Yes,” describe:

c. Are there saunas and/or hot tubs? (80902) Yes No If “Yes,” how many?

Is there an attendant on duty? Yes No If “Yes,” how many hours per day is the attendant on duty?

d. Are there tennis/racquetball/handball courts? (80903) Yes No If “Yes,” how many?

e. Are there exercise/weight rooms? (80904) Yes No If “Yes,” how many:

Is there an attendant on duty? Yes No If “Yes,” how many hours per day is the attendant on duty?

Are there treadmills? Yes No

f. Are there indoor parking facilities? (80910) Yes No If “Yes,” how many parking spaces:

g. Is there a Community Center? (80922) Yes No If “Yes,” how many square feet in area:

h. Is the facility used for activities other than by residents? Yes No If “Yes,” describe:

i. Is the restaurant open to the public? Yes No

Gross receipts: $

Is liquor served? Yes No

VI. Administrator

18. Name of Administrator: License Number: State:

19. Length of time at this facility: Length of time as Nursing Home Administrator (NHA):

Full time at this facility? Yes No Number of hours at this facility per week?

VII. Nurse Staffing

20. Director of Nursing (DON):

Name: Professional credentials: RN LPN

Length of time at this facility: Length of time as DON:

21. a. Total # of nurse employees:

b. By category:

c. Do you require nurses to carry malpractice coverage? Yes No

d. Do you obtain and review nurses’ certificates of malpractice insurance? Yes No

e. Do you verify nursing licenses upon hire and annually? Yes No

f. Do you verify nursing assistant certification upon hire and annually? Yes No

g. Are background checks completed for agency and pool employees? Yes No

VIII. Physicians and Medical Director

22. Number of physicians: Employed: Affiliated: Contracted:

23. Do you obtain and review physicians’ certificates of malpractice insurance? Yes No

24. Do you require limits of liability comparable to your own? Yes No

If “No,” define the differences in limits:

25. a. Are the physicians credentialed? Yes No

b. Do credentialing activities include

(i) Verification of current professional license? Yes No

(ii) Verification of current DEA license? Yes No

26. Name of Medical Director: License Number: State:

27. Length of time as Medical Director: Medical Specialty:

Full-time at this facility Part-time at this facility Number of hours at this facility per week:

28. Does the Medical Director also act as the attending physician to any residents? Yes No

If “Yes,” how many:

IX. Staff/Employee Selection and Hiring

32. Is there a formal, documented assessment process to measure staff competency skills? Yes No

33. Do you conduct an orientation and regularly scheduled in-service education programs for all staff/employees? Yes No

34. How are employees recruited?

35. Describe background verification checks on new employees:

a. work history? Yes No

b. education? Yes No

c. criminal record? Yes No

d. driving record - Motor Vehicle Record (MVR) when appropriate? Yes No

e. drug testing? Yes No

X. Non-Resident Services

36. Please indicate the annual number of visits or clients for the following

Home Health Care Yes No # of Home Health Care visits or clients per year:

Is home health care provided by independent contractors? Yes No

Describe home health care services:

Adult Day Care Total Licensed #: Average Occupancy: Hours of Operation:

Is this a licensed adult day care center? Yes No # of Employees:

Do you provide transportation to and from your facility? Yes No

Do you provide transportation to and from events? Yes No

Is a physical examination performed by a physician prior to admission? Yes No

If “Yes,” describe:

Are medical services provided? Yes No

If “Yes,” describe:

Children Day Care Total Licensed #) Average Occupancy: Hours of Operation:

# of employees: # of children: # of employees’ children:

Do you provide any transportation for children? Yes No

If “Yes,” describe:

Respite Care: Yes No If “Yes,” # per year:

Hospice Care (80931): Yes No If “Yes,” # per year:

Rehabilitation Services: Yes No If “Yes,” # per year:

Describe in-house rehabilitation services:

37. Do you provide the following services?

38. Do you provide any other services to your residents or the community? Yes No

If “Yes,” describe:

XI. Consultants/Independent Contractors and Services

39. Indicate which of the following services are (1) contracted to you at this facility, (2) if a contract is in place and (3) limits of liability:

40. Have certificates of insurance been obtained from independent contractors? Yes No

Are these reviewed annually? Yes No

If “Yes,” are limits of liability the same as your limits of liability? Yes No

If “No,” explain:

XII. Volunteers

41. a. What is the total number of volunteers?

b. What are the primary sources for volunteers?

c. Is there a formal screening and orientation process for volunteers? Yes No

Explain:

d. Are roles & responsibilities of volunteers clearly communicated to staff and volunteers? Yes No

e. Do volunteers assist with resident feeding? Yes No

XIII. Risk Management

42. Is there a risk management program implemented throughout this facility? Yes No

43. Is there a designated risk manager? Yes No

If “Yes,” indicate risk manager’s name:

How long has the risk manager been in that position?

44. a. Is there an “incident reporting” policy? Yes No

b. Are all incident reports reviewed by the risk manager and medical director? Yes No

c. Are incidents trended and presented to the quality/risk management committee? Yes No

45. a. Is there a formal safety program? Yes No

b. Does it include evaluation and reduction of exposures relating to:

(i) Life safety? Yes No

(ii) Employees? Yes No

(iii) Hazardous materials? Yes No

(iv) Environment? Yes No

46. a. Is there a formal preventive maintenance program? Yes No

b. Is responsibility for the program assigned to one individual? Yes No

c. Does the program include:

(i) Evaluation of all electrical devices/equipment brought into the facility? Yes No

(ii) Scheduled evaluations of equipment and devices including electrical supply? Yes No

(iii) Retention of maintenance and inspection records? Yes No

47. What security measures are used to control unauthorized entrances and exits from the facility?

48. a. Are WanderGuards or similar devices used as part of elopement prevention practices? Yes No

If “Yes,” provide type:

b. Are WanderGuard devices for residents and building maintained and inspected according to manufacturer’s specifications? Yes No

c. Number of elopements in past three years:

49. Are nursing assessment protocols in place to identify residents at risk for:

a. Elopement? Yes No

b. Falls? Yes No

c. Cognitive Impairment? Yes No

d. Nutritional Deficiency? Yes No

XIV. Additional Property/Life Safety Information

58. Construction

a. Type of construction: Year built: # of floors: # of elevators:

b. Date of inspection: Electrical: Plumbing: HVAC:

c. Was the building constructed for this occupancy? Yes No

If “No,” please explain:

d. Have there been any water damage incidents in the past five (5) years? Yes No

If “Yes,” have they been corrected? Yes No

If “Yes,” describe:

e. Are all vertical openings (stairwells, elevators, dumbwaiters, etc.) protected and enclosed with self-enclosing doors and wall structures having a minimum 1-hour fire rating? Yes No

If “No,” please explain:

f. Type of wiring (copper or aluminum): Type of roof:

Type of pipe used in your water or sewerage system (PVC/Iron/Copper):

g. Has your building ever sustained foundation damage? Yes No

If “Yes,” describe:

h. (i) Is there a scheduled service to clean heating and ventilation ducts? Yes No

(ii) How often are ducts cleaned?

59. Occupancy

a. Are there other occupancies in the building not related to resident care? Yes No

If “Yes,” describe:

b. Is there a facility “no smoking” policy in effect? Yes No

c. Are smoking materials (including matches and lighters) restricted from a resident’s room? Yes No

d. Are smoking residents supervised and/or in designated areas? Yes No

e. How many exits (other than front doorway) are there?

f. Are these equipped with panic alarms? Yes No

g. Do alarms ring into central security desk or nurses station? Yes No

h. Are there at least two remote exits on each floor? Yes No

60. Protection

a. Is risk protected (100%) throughout by an automatic sprinkler system and have these systems been tested by a qualified contractor with results documented? Yes No

If not 100%, please advise which areas are not protected:

If not tested, please explain:

b. Are all alarm signals monitored by a UL-approved central station or the responding fire department? Yes No

c. Is there a written emergency plan covering fire, natural disasters and threats: Yes No

If “Yes,” do employees receive instruction training regarding this plan? Yes No

d. Has the fire department pre-planned emergency procedures at this location: Yes No

If “Yes,” indicate the last date when these procedures were update:

e. When was facility last inspected by local fire authorities:

f. Is there a bulk medical gas distribution system piped in the building? Yes No

If “Yes,” are emergency shutoffs provided? Yes No

If “No,” is there storage of individual tanks? Yes No

If “Yes,” are these tanks on rolling carts? Yes No

Are they properly chained? Yes No

g. In cooking areas (other than independent living units), is there a fire suppression system? Yes No

(i) Is there a hood and grease filter? Yes No

(ii) What is the frequency of cleaning (i.e. monthly/quarterly)?

(iii) Do you use an outside contractor for cleaning? Yes No

(iv) Is the area equipped with an automatic fuel shutoff? Yes No

h. Are hardwire smoke detectors in resident rooms/apartments? Yes No

i. Are doors equipped with approved self-closing devices where required? Yes No

j. Total # of fire extinguishers:

k. Who is the sprinkler manufacturer and what type of sprinkler heads are used?

l. If a multi-story building, are non-ambulatory residents on lower floors (1st/2nd)? Yes No

m. Are corridors, doors, ramps, stairs, etc. free and clear of obstructions? Yes No

n. Is video surveillance used? Yes No If “Yes,” describe extent of use:

o. Are fire drills conducted regularly? Yes No If “Yes,” describe:

p. Are emergency call buttons in each room/unit? Yes No

q. Are intercoms or bells provided in each resident room? Yes No

r. Are handrails provided in hallways and bathrooms? Yes No

s. Are bathtubs/showers equipped with non-slip surfaces? Yes No

61. Exposure

a. How many miles is the facility located from the coast? miles

b. Is risk located in a federally classified earthquake zone? Yes No If “Yes,” what zone?

c. Is risk located on a fault? Yes No

d. Is risk in a flood zone? Yes No

If “Yes,” what zone?

XV. Commercial Automobile

62. Do you contract with a transport service (i.e. ambulance, buses, vans) to transport residents? Yes No

If “Yes,” what is the name of the transport service?

Contact Name: Telephone Number:

63. Do employees transport residents in their own automobiles? Yes No

If “Yes,” describe: Average frequency:

64. Do you require them to carry minimum insurance limits? Yes No

If “Yes,” what limits are required? $

65. a. Do you have any Commercial Driver’s License vehicles? Yes No

b. If “Yes,” how many:

66. Do volunteers operate any vehicles? Yes No

67. Are driving records reviewed annually? Yes No

WARRANTY:

I HAVE ANSWERED THE QUESTIONS IN THE APPLICATION TO THE BEST OF MY ABILITY AND DECLARE THAT, TO THE BEST OF MY KNOWLEDGE, THE STATEMENTS SET FORTH HEREIN ARE TRUE AND CORRECT. MY SIGNING OF THE APPLICATION DOES NOT BIND THE INSURANCE COMPANY TO ISSUE AN INSURANCE POLICY, BUT IT IS AGREED THAT THIS APPLICATION SHALL BE THE BASIS OF THE CONTRACT SHOULD A POLICY BE ISSUED. I FURTHER UNDERSTAND THAT ANY INCORRECT OR INCOMPLETE STATEMENT IN THE APPLICATION COULD VOID MY PROTECTION SHOULD A POLICY BE ISSUED.

FRAUD NOTICE – WHERE APPLICABLE UNDER THE LAW OF YOUR STATE

Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false or incomplete information, or conceals, for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime AND MAY BE SUBJECT TO CIVIL FINES AND CRIMINAL PENALTIES (for New York residents only: and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.) (For Pennsylvania residents only: Any person who knowingly and with intent to injure or defraud any insurer files an application or claim containing any false, incomplete or misleading information shall, upon conviction, be subject to imprisonment for up to seven year and payment of a fine of up to $15,000.) (For Tennessee residents only: Penalties include imprisonment, fines and denial of insurance benefits.)

Application is made to CNA member property-casualty companies. This program is not available outside the United States. CNA is a registered service mark and trade name of CNA Financial Corporation.