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Apply Online

If available, please upload a copy of the Declaration Page (“Face Sheet”) for the Professional Liability Policy that you currently have in place. If this is not available for upload at this time, we will be in contact with you to obtain this information after you submit this online application.

  • Contact Information

  • 1.
  • Person to contact for survey
  • 2.
  • Number of estimated client contacts
  • Annual Gross Receipts
    $ $
  • Total Annual Payroll
    $ $
  • 3.
  • Entity is
  • Are you affiliated with a national or regional network or association?
  • 4.
  • 5.
  • 6.
  • Indicate each treatment modality used by the applicant
  • 7.
  • Do you maintain records that indicate the total number of clients seen by each therapist, aide, and assistant?
  • 8.
  • Does any one therapist, aide or assistant represent 25% or more of your total revenue?
  • 9.
  • Are employees that lift clients or assist clients in weight-bearing movements required to wear back support?
  • 10.
  • Do you have procedures in place for the handling of your larger clients?
  • 11.
  • Do you require any employee that is injured while providing your services to clients to go to the emergency room or their own primary care physician?
  • 12.
  • Do you require an official release from the emergency room or PCP prior to the employee returning to work?
  • 13.
  • If the injured employee cannot return to work immediately, do you hire temporary workers to replace him/her?
  • 14.
  • Is it your intent in the absence of a key member of your staff to maintain the same client base and not to reduce the annual number of clients seen?
  • 15.
  • Does applicant provide physical therapy services only as prescribed by a physician?
  • 16.
  • Do you keep daily work reports on all patients as they are seen?
  • 17.
  • Approximately what percentage of applicant’s patients are:
  • 18.
  • Has applicant treated any professional or collegiate athletes?
  • 19.
  • Are any tests conducted/results interpreted or diagnosed by applicant?
  • 20.
  • How many employees/independent contractors do you employ in each of the following positions:
  • 21.
  • Does applicant check all driver’s MVRs?
    Does applicant require drivers to carry auto insurance with limits as required by state law?
    Does applicant have owned, leased or hired autos used in business?

    Have any auto claims been made or occurrences reported during the past 5 years?
  • 22.
  • Does applicant have written screening and hiring policies and procedures for all prospective employees, students, independent contractors/consultants and volunteers?
    Are there written guidelines regarding sexual misconduct or physical abuse?
    Do you perform criminal background checks as part of your employee screening process?
    Has the applicant had any incidents or claims reported for sexual misconduct or any other allegation of abuse?
    Has the applicant or any of its employees:
    a) Ever been the subject of disciplinary or investigatory proceedings or reprimanded by an administrative or governmental agency, hospital or professional association?
    b) Had any professional license refused, suspended, revoked, renewal refused or accepted only with special terms or has applicant or any of its employees voluntarily surrendered any professional license?
    c) Been convicted for an act committed in violation of any law or ordinance other than traffic offenses?
  • 23.
  • Do you have a formal risk management procedure in place?
  • IF THE ANSWER TO ANY OF THE ABOVE IS YES, PLEASE ATTACH A DETAILED EXPLANATION.
  • 24.
  • Have any claims been made or occurrences reported during the past five years against any of the proposed insureds or against any entity in which any proposed insured has or has had an interest?
  • 25.
  • Does any proposed insured have any knowledge of an event, circumstance or occurrence (other than any listed in #13 above) prior to the effective date of the proposed policy, or does any proposed insured foresee that a claim may be brought as a result of said event, circumstance or occurrence?
  • 26.
  • Do you require all insured's, including employees and contractors to report ALL incidents to the Named Insured no later than the end of the workday on which the incident occurred?
  • I understand and agree this application and any and all supplements attached hereto may be made a part of any policy issued, and any such policy will be issued in reliance upon the representation made herein. I further understand and agree that failure to provide a true and accurate response to the foregoing questions may, at the option of the Company, result in the voiding of insurance issued in reliance on this application and/or denial of claims under any policy issued.
  • I authorize and consent to investigations of information bearing upon moral character, professional reputation and fitness to engage in the activities of my business including authorization to every person or entity, public or private, to release to the company providing insurance coverage and Mid-Continent General Agency, Inc. any documents, records or other information bearing upon the foregoing.
  • I understand and agree these investigations shall not be confined to information submitted in this application, but shall include any other sources of information deemed relevant by the Company as may be authorized by law.
  • Applicant and all owners, employees, and contractors are licensed or duly authorized in all states or jurisdictions where professional services are provided. Applicant warrants the truth of all answers to the above questions, and that applicant has not withheld any information that is calculated to influence the judgment of the insurance company in considering this application.
    IMPORTANT: THIS APPLICATION MUST BE SIGNED BY THE APPLICANT. SIGNING THIS FORM DOES NOT BIND THE COMPANY TO COMPLETE THE INSURANCE.