Affinity Healthcare Non-Emergency Medical Transportation Insurance Application Instructions
This form contains 352 fields organized into 108 sections. Below is a complete list of every field, its type, and what information is expected.
| Field Name | Type | Description |
|---|---|---|
| Accommodated Wheelchair Types | ||
| Portable | Checkbox |
Check this box if the vehicles accommodate portable wheelchairs.
|
| Motorized | Checkbox |
Check this box if the vehicles accommodate motorized wheelchairs.
|
| Youth/Child Stroller | Checkbox |
Check this box if the vehicles accommodate youth or child strollers.
|
| Tri-Wheeler/Scooter | Checkbox |
Check this box if the vehicles accommodate tri-wheelers or scooters.
|
| Lightweight | Checkbox |
Check this box if the vehicles accommodate lightweight wheelchairs.
|
| Heavy Duty Industrial | Checkbox |
Check this box if the vehicles accommodate heavy duty industrial wheelchairs.
|
| Reclining/Tilting | Checkbox |
Check this box if the vehicles accommodate reclining or tilting wheelchairs.
|
| ADA Compliance Inquiry | ||
| Yes | Radiobutton |
Check this box if all vehicles comply with ADA standards.
|
| No | Radiobutton |
Check this box if not all vehicles comply with ADA standards.
|
| Aftermarket Vehicle Modifications | ||
| Yes | Radiobutton |
Check this box if the applicant performs aftermarket vehicle modifications.
|
| No | Radiobutton |
Check this box if the applicant does not perform aftermarket vehicle modifications.
|
| Explanation of Aftermarket Modifications | Text |
Provide a detailed explanation of any aftermarket vehicle modifications that have been performed. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Annual MVR Review | ||
| Yes | Radiobutton |
Check this box if the owner reviews Motor Vehicle Records (MVRs) for all drivers annually.
|
| No | Radiobutton |
Check this box if the owner does not review Motor Vehicle Records (MVRs) for all drivers annually.
|
| Applicant Standards for an Acceptable MVR | ||
| MVR Standards | Text |
Please describe the applicant's standards for an acceptable Motor Vehicle Record (MVR). Fill only if 'Motor Vehicle Record Check' is 'Yes'.
Depends on:
Motor Vehicle Record Check
|
| Applicant's Hours of Operation | ||
| Hours of Operation | Text |
Please provide the applicant's hours of operation.
|
| Attendant for Stretcher Clients | ||
| Yes | Radiobutton |
Check this box if an attendant does accompany stretcher clients.
|
| No | Radiobutton |
Check this box if an attendant does not accompany stretcher clients.
|
| Attendant Type | ||
| Employee of Applicant | Checkbox |
Check this box if the attendant accompanying stretcher clients is an employee of the applicant. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Personal Assistant of Client | Checkbox |
Check this box if the attendant accompanying stretcher clients is a personal assistant of the client. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Employee of Requesting Organization | Checkbox |
Check this box if the attendant accompanying stretcher clients is an employee of the organization requesting transport. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Basis for Driver Pay | ||
| Salary | Checkbox |
Check this box if driver pay is based on a salary.
|
| Hourly | Checkbox |
Check this box if driver pay is based on an hourly wage.
|
| Trip | Checkbox |
Check this box if driver pay is based on a per-trip rate.
|
| Mileage | Checkbox |
Check this box if driver pay is based on mileage.
|
| Other | Checkbox |
Check this box if driver pay is based on a method not listed.
|
| Call Dispatcher | ||
| Call Dispatcher | Text |
Provide the name or title of the individual or entity responsible for dispatching calls for the applicant.
|
| Call Reports Completion Status | ||
| Yes | Radiobutton |
Check this box if call reports are completed on every call and/or run. Fill only if 'Has the applicant entered into any written contractual agreements to perform ambulance service for a
government entity, hospital, or nursing home?' is 'Yes'.
Depends on:
Yes
|
| No | Radiobutton |
Check this box if call reports are not completed on every call and/or run. Fill only if 'Has the applicant entered into any written contractual agreements to perform ambulance service for a
government entity, hospital, or nursing home?' is 'Yes'.
Depends on:
Yes
|
| Call Screening Measures | ||
| Call Screening Measures Use | Text |
Please indicate if call screening measures are utilized to determine the use of lights and sirens by the dispatcher.
|
| Cell Phone Use Restrictions | ||
| Yes | Radiobutton |
Check this box if there are restrictions on the use of cell phones/hand-helds while operating vehicles. Fill only if 'Has the applicant entered into any written contractual agreements to perform ambulance service for a
government entity, hospital, or nursing home?' is 'Yes'.
Depends on:
Yes
|
| No | Radiobutton |
Check this box if there are no restrictions on the use of cell phones/hand-helds while operating vehicles. Fill only if 'Has the applicant entered into any written contractual agreements to perform ambulance service for a
government entity, hospital, or nursing home?' is 'Yes'.
Depends on:
Yes
|
| Circumstances Resulting in Claim | ||
| Yes | Radiobutton |
Check this box if the applicant is aware of any circumstances that may result in a claim.
|
| No | Radiobutton |
Check this box if the applicant is not aware of any circumstances that may result in a claim.
|
| Details of Potential Claim Circumstance | Text |
Provide full details of any circumstances known to the applicant that may result in a claim. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Contractual Agreements | ||
| Contractual Agreements Explanation | Text |
Explain the details of any written contractual agreements the applicant has entered into with a government entity, hospital, or nursing home to perform ambulance service. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Yes | Radiobutton |
Check this box if the applicant has entered into any written contractual agreements to perform ambulance service for a government entity, hospital, or nursing home.
|
| No | Radiobutton |
Check this box if the applicant has not entered into any written contractual agreements to perform ambulance service for a government entity, hospital, or nursing home.
|
| Current Year and Projected Revenues | ||
| Expiring Past 12 Months Revenue | Number |
Please enter the total revenue for the past 12 months.
|
| Projected 12 Months Revenue | Number |
Please enter the projected total revenue for the next 12 months.
|
| DECLARATION AND CERTIFICATION | ||
| Declaration Date | Date |
Provide the date when the declaration is being signed. Fill only if 'Declaration Date' is not empty.
|
| Applicant's Title | Text |
Enter the applicant's job title or position. Fill only if 'Applicant's Title' is not empty.
|
| Different Operating Name History | ||
| Yes | Radiobutton |
Check this box if the company has ever operated under a different name.
|
| No | Radiobutton |
Check this box if the company has never operated under a different name.
|
| Driver Age Groups | ||
| Drivers Over 70 | Number |
Please provide the number of drivers who are over 70 years old.
|
| Drivers Under 23 | Number |
Please provide the number of drivers who are under 23 years old.
|
| Driver Counts by Category | ||
| Total Number of Drivers | Text | |
| Full-Time Drivers | Text | |
| Volunteer Drivers | Text | |
| Part-Time Drivers | Text | |
| Backup Drivers | Text | |
| Contracted Drivers | Text | |
| Driver Counts by Type | ||
| EMT | Text | |
| First Responder Driver Count | Text |
Enter the number of drivers who are certified as First Responders.
|
| Paramedic Driver Count | Text |
Enter the number of drivers who are certified as Paramedics.
|
| General Driver Count | Text |
Enter the number of drivers who serve in a general driving capacity.
|
| Other Driver Count | Text |
Enter the number of drivers who fall into other categories not explicitly listed.
|
| Driver Safety Incentive Plan | ||
| Yes | Radiobutton |
Check this box if a driver safety incentive plan is currently in place. Fill only if 'Has the applicant entered into any written contractual agreements to perform ambulance service for a
government entity, hospital, or nursing home?' is 'Yes'.
Depends on:
Yes
|
| No | Radiobutton |
Check this box if there is no driver safety incentive plan currently in place. Fill only if 'Has the applicant entered into any written contractual agreements to perform ambulance service for a
government entity, hospital, or nursing home?' is 'Yes'.
Depends on:
Yes
|
| Safety Incentive Plan Description | Text |
Provide a detailed description of the driver safety incentive plan. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Driver Training Percentages | ||
| General Driver Orientation | Text | |
| Defensive Driving | Text | |
| CPR | Text | |
| Primary First Aid | Text | |
| Advanced First Aid | Text | |
| Passenger Assistance | Text | |
| Non-Medical Emergency Training | Text | |
| Emergency Vehicle Evacuation | Text | |
| Proper Wheelchair/Stretcher Securement Procedures | Text | |
| Driver Turnover | ||
| Drivers Added | Text |
Enter the number of drivers added in the past twelve months.
|
| Drivers Replaced | Text |
Enter the number of drivers replaced in the past twelve months.
|
| Drug and Alcohol Free Workplace Status | ||
| Yes | Radiobutton |
Check this box if the applicant maintains a drug and alcohol-free workplace. Fill only if 'Has the applicant entered into any written contractual agreements to perform ambulance service for a
government entity, hospital, or nursing home?' is 'Yes'.
Depends on:
Yes
|
| No | Radiobutton |
Check this box if the applicant does not maintain a drug and alcohol-free workplace. Fill only if 'Has the applicant entered into any written contractual agreements to perform ambulance service for a
government entity, hospital, or nursing home?' is 'Yes'.
Depends on:
Yes
|
| Employee Loading and Unloading of Stretchers | ||
| Yes | Radiobutton |
Check this box if employees load and unload the stretchers.
|
| No | Radiobutton |
Check this box if employees do not load and unload the stretchers.
|
| Exclusive Transport of Non-Ambulatory Individuals | ||
| Yes | Radiobutton |
Check this box if vehicles equipped with lifts or ramps exclusively transport non-ambulatory individuals.
|
| No | Radiobutton |
Check this box if vehicles equipped with lifts or ramps do not exclusively transport non-ambulatory individuals.
|
| Experience Requirement | ||
| Experience Requirement | Text |
Provide the specific experience requirement for newly hired drivers. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Yes | Radiobutton |
Check this box if there is an experience requirement for newly hired drivers.
|
| No | Radiobutton |
Check this box if there is no experience requirement for newly hired drivers.
|
| Expiring Policy Information | ||
| Expiring Vehicle Count | Number |
Enter the total number of vehicles for the expiring policy term.
|
| Expiring Number of Transports | Number |
Enter the total number of transports for the expiring policy term.
|
| Factory Installed Equipment | ||
| Yes | Radiobutton |
Check this box if all equipment was factory installed during vehicle construction.
|
| No | Radiobutton |
Check this box if not all equipment was factory installed during vehicle construction.
|
| First Auto Liability Insurance Coverage | ||
| Occurrence | Checkbox |
Check this box if the first auto liability insurance policy listed provides occurrence-based coverage.
|
| Premium Amount | Number |
Enter the premium amount paid for the first year of auto liability insurance coverage.
|
| Company Name | Text |
Enter the name of the insurance company providing auto liability coverage for the first year.
|
| Policy Period | Text |
Enter the policy period for the auto liability insurance coverage for the first year.
|
| Limits of Liability Per Occurrence | Number |
Enter the per occurrence limit of liability for the first year of auto liability insurance coverage.
|
| Limits of Liability Aggregate | Number |
Enter the aggregate limit of liability for the first year of auto liability insurance coverage.
|
| Retention Per Occurrence | Number |
Enter the per occurrence retention amount for the first year of auto liability insurance coverage.
|
| Deductible Aggregate | Number |
Enter the aggregate deductible amount for the first year of auto liability insurance coverage.
|
| First General Liability Insurance Coverage | ||
| Claims-Made | Checkbox |
Check this box if the general liability insurance coverage for this policy is on a claims-made basis.
|
| Occurrence | Checkbox |
Check this box if the general liability insurance coverage for this policy is on an occurrence basis.
|
| Company Name | Text |
Enter the name of the insurance company that provided the general liability coverage for this period.
|
| Premium | Number |
Enter the premium amount for the general liability insurance policy.
|
| Policy Period | Text |
Enter the policy period for the general liability insurance coverage.
|
| Limits of Liability (First) | Number |
Enter the first limit of liability for the general liability insurance policy.
|
| Retention Amount | Number |
Enter the retention amount for the general liability insurance policy.
|
| Deductible Amount | Number |
Enter the deductible amount for the general liability insurance policy.
|
| Retro Date | Date |
Enter the retro date for the claims-made general liability insurance policy. Fill only if 'Claims-Made' is 'Yes'.
Depends on:
Claims-Made
|
| First Named Insured | ||
| First Named Insured Legal Name | Text |
Provide the legal name of the parent entity to be first named insured, exactly as it shall be shown on the policy.
|
| First Prior Policy Information | ||
| First Prior Vehicle Count | Number |
Please provide the total number of vehicles for the first prior policy.
|
| First Prior Number of Transports | Number |
Please provide the total number of transports for the first prior policy.
|
| First Professional Liability Insurance Coverage | ||
| Premium | Number |
Enter the premium amount for the first professional liability coverage.
|
| Retroactive Date | Date |
Enter the retroactive date for the first professional liability claims-made policy, if applicable. Fill only if 'Claims-Made' is 'Yes'.
Depends on:
Claims-Made
|
| Claims-Made | Checkbox |
Check this box if the professional liability insurance coverage is based on a claims-made policy, meaning it covers claims reported during the policy period.
|
| Occurrence | Checkbox |
Check this box if the professional liability insurance coverage is based on an occurrence policy, meaning it covers incidents that occur during the policy period, regardless of when the claim is reported.
|
| Company Name | Text |
Provide the name of the insurance company for the first professional liability coverage.
|
| Policy Period | Text |
Enter the start and end dates for the first professional liability insurance policy period.
|
| Limits of Liability Per Occurrence/Claim | Number |
Enter the per-occurrence or per-claim limit of liability for the first professional liability coverage.
|
| Limits of Liability Aggregate | Number |
Enter the aggregate limit of liability for the first professional liability coverage.
|
| Retention Amount | Number |
Enter the retention amount for the first professional liability coverage.
|
| Deductible Amount | Number |
Enter the deductible amount for the first professional liability coverage.
|
| Fleet's Total Mileage Last Year | ||
| Fleet Total Mileage Last Year | Number |
Please provide the total mileage accumulated by the fleet in the last year.
|
| Formal Accident Investigation Procedures | ||
| Yes | Radiobutton |
Check this box if formal accident investigation and review procedures are in place. Fill only if 'Has the applicant entered into any written contractual agreements to perform ambulance service for a
government entity, hospital, or nursing home?' is 'Yes'.
Depends on:
Yes
|
| No | Radiobutton |
Check this box if formal accident investigation and review procedures are not in place. Fill only if 'Has the applicant entered into any written contractual agreements to perform ambulance service for a
government entity, hospital, or nursing home?' is 'Yes'.
Depends on:
Yes
|
| Fourth Prior Policy Information | ||
| Fourth Prior Vehicle Count | Number |
Enter the total number of vehicles for the fourth prior policy term.
|
| Fourth Prior Number of Transports | Number |
Enter the total number of transports for the fourth prior policy term.
|
| Full-time Safety Director Status | ||
| Yes | Radiobutton |
Check this box if the insured organization employs a full-time Safety Director. Fill only if 'Has the applicant entered into any written contractual agreements to perform ambulance service for a
government entity, hospital, or nursing home?' is 'Yes'.
Depends on:
Yes
|
| No | Radiobutton |
Check this box if the insured organization does not employ a full-time Safety Director. Fill only if 'Has the applicant entered into any written contractual agreements to perform ambulance service for a
government entity, hospital, or nursing home?' is 'Yes'.
Depends on:
Yes
|
| General | ||
| Applicant’s Signature | Signature | |
| GPS for Driver Behavior Monitoring | ||
| Yes | Radiobutton |
Check this box if the applicant uses global positioning systems (GPS) to monitor driver behavior. Fill only if 'Has the applicant entered into any written contractual agreements to perform ambulance service for a
government entity, hospital, or nursing home?' is 'Yes'.
Depends on:
Yes
|
| No | Radiobutton |
Check this box if the applicant does not use global positioning systems (GPS) to monitor driver behavior. Fill only if 'Has the applicant entered into any written contractual agreements to perform ambulance service for a
government entity, hospital, or nursing home?' is 'Yes'.
Depends on:
Yes
|
| Instruction on Proper Use of Securement Equipment | ||
| Yes | Radiobutton |
Check this box if all persons involved in wheelchair transportation are instructed in the proper use of securement equipment for all types of wheelchairs.
|
| No | Radiobutton |
Check this box if not all persons involved in wheelchair transportation are instructed in the proper use of securement equipment for all types of wheelchairs.
|
| Instructions | ||
| Sample Checkbox Indicator | Checkbox |
Check this box by entering '1' when providing Yes or No answers and other selections as instructed.
|
| Interstate Operation and Details | ||
| Yes | Radiobutton |
Check this box if your operating radius crosses state lines.
|
| No | Radiobutton |
Check this box if your operating radius does not cross any state lines.
|
| States Operating In | Text |
If the operating radius crosses state lines, please list the specific states where operations occur. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Mailing Address | ||
| Street | Text |
Please provide the street address for the mailing address.
|
| City | Text |
Please provide the city for the mailing address.
|
| State | Text |
Please provide the state for the mailing address.
|
| Zip Code | Text |
Please provide the zip code for the mailing address.
|
| County | Text |
Please provide the county for the mailing address.
|
| Maintenance Performance Frequency | ||
| Maintenance Frequency | Text |
Provide a description of how often vehicle maintenance is performed.
|
| Maintenance Performer | ||
| In-house | Checkbox |
Check this box if maintenance on the fleet is performed by internal staff.
|
| Outside Service | Checkbox |
Check this box if maintenance on the fleet is performed by an external service provider.
|
| Maintenance Repair Records on File Inquiry | ||
| Yes | Radiobutton |
Check this box if the applicant keeps maintenance repair records on file for all vehicles.
|
| No | Radiobutton |
Check this box if the applicant does not keep maintenance repair records on file for all vehicles.
|
| Major Metropolitan Service Areas | ||
| Atlanta GA | Checkbox |
Check this box if services are provided in the Atlanta, GA metropolitan area.
|
| Boston MA | Checkbox |
Check this box if services are provided in the Boston, MA metropolitan area.
|
| Chicago IL | Checkbox |
Check this box if services are provided in the Chicago, IL metropolitan area.
|
| Houston TX | Checkbox |
Check this box if services are provided in the Houston, TX metropolitan area.
|
| Los Angeles CA | Checkbox |
Check this box if services are provided in the Los Angeles, CA metropolitan area.
|
| San Francisco CA | Checkbox |
Check this box if services are provided in the San Francisco, CA metropolitan area.
|
| Seattle WA | Checkbox |
Check this box if services are provided in the Seattle, WA metropolitan area.
|
| Washington DC | Checkbox |
Check this box if services are provided in the Washington, DC metropolitan area.
|
| Miami FL | Checkbox |
Check this box if services are provided in the Miami, FL metropolitan area.
|
| New York City, NY incl the 5 boroughs | Checkbox |
Check this box if services are provided in the New York City, NY metropolitan area, including the 5 boroughs.
|
| Philadelphia PA | Checkbox |
Check this box if services are provided in the Philadelphia, PA metropolitan area.
|
| Mandated Driver Training Frequency | ||
| Annual Training Frequency | Text |
Please provide the frequency of mandated driver training provided annually.
|
| Bi-Annual Training Frequency | Text |
Please provide the frequency of mandated driver training provided bi-annually.
|
| Other Training Frequency | Text |
Please specify any other frequency for mandated driver training not covered by annual or bi-annual options. Fill only if 'Annual Training Frequency', 'Bi-Annual Training Frequency' is not selected.
Depends on:
Annual Training Frequency, Bi-Annual Training Frequency
|
| Manufacturer Certification Inquiry | ||
| Yes | Radiobutton |
Check this box if the maintenance providers for the fleet are certified by the manufacturer.
|
| No | Radiobutton |
Check this box if the maintenance providers for the fleet are not certified by the manufacturer.
|
| Maximum Accidents Allowance | ||
| If yes, how many | Text |
Depends on:
Yes
|
| Yes | Radiobutton |
Check this box if there is a maximum number of accidents allowed. Fill only if 'Has the applicant entered into any written contractual agreements to perform ambulance service for a
government entity, hospital, or nursing home?' is 'Yes'.
Depends on:
Yes
|
| No | Radiobutton |
Check this box if there is no maximum number of accidents allowed. Fill only if 'Has the applicant entered into any written contractual agreements to perform ambulance service for a
government entity, hospital, or nursing home?' is 'Yes'.
Depends on:
Yes
|
| Maximum Driving Violations Allowance | ||
| Maximum Violations Allowed | Text |
Enter the maximum number of driving violations allowed for drivers. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Yes | Radiobutton |
Check this box if there is a maximum number of driving violations allowed. Fill only if 'Has the applicant entered into any written contractual agreements to perform ambulance service for a
government entity, hospital, or nursing home?' is 'Yes'.
Depends on:
Yes
|
| No | Radiobutton |
Check this box if there is no maximum number of driving violations allowed. Fill only if 'Has the applicant entered into any written contractual agreements to perform ambulance service for a
government entity, hospital, or nursing home?' is 'Yes'.
Depends on:
Yes
|
| Minimum Age Requirement | ||
| Yes | Radiobutton |
Check this box if there is a minimum age requirement for drivers.
|
| No | Radiobutton |
Check this box if there is no minimum age requirement for drivers.
|
| Minimum Age | Text |
Enter the minimum age requirement for drivers. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| MVR Check Frequency | ||
| MVR Check Frequency | Text |
Enter how often Motor Vehicle Records (MVRs) are checked for all drivers.
|
| Number of Annual Calls | ||
| Emergency (911) Calls | Number |
Please indicate the number of annual emergency calls (911).
|
| Ambulatory Transports Calls | Number |
Please indicate the number of annual ambulatory transport calls.
|
| Non-Emergency (Ambulance) Calls | Number |
Please indicate the number of annual non-emergency calls involving an ambulance.
|
| Wheelchair Transports Calls | Number |
Please indicate the number of annual wheelchair transport calls.
|
| Non-911 Dispatch Services Calls | Number |
Please indicate the number of annual calls for non-911 dispatch services.
|
| School Transports Calls | Number |
Please indicate the number of annual school transport calls.
|
| Child/Youth (under 18) Calls | Number |
Please indicate the number of annual calls for children or youth under 18 years old.
|
| Other Calls | Number |
Please indicate the number of annual calls for other specified categories.
|
| Number of Vehicles Equipped with Lifts | ||
| Number of Vehicles with Lifts | Number |
Please enter the total number of vehicles that are equipped with lifts.
|
| Number of Vehicles Equipped with Ramps | ||
| Number of Vehicles with Ramps | Text |
Enter the total number of vehicles that are equipped with ramps.
|
| Number of Vehicles with Stretcher Equipment | ||
| 42. How many vehicles are equipped with stretcher equipment | Text | |
| Operations Start Year | ||
| Operations Start Year | Number |
Provide the year when the business operations commenced.
|
| Personal Use of Vehicles | ||
| Yes | Radiobutton |
Check this box if there is any personal use of vehicles, including owners/employees taking vehicles home.
|
| No | Radiobutton |
Check this box if there is no personal use of vehicles, including owners/employees taking vehicles home.
|
| Personal Use Description | Text |
Provide a detailed explanation of the personal use of vehicles by owners or employees, especially if vehicles are taken home. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Post-Accident Drug Testing Policy | ||
| Yes | Radiobutton |
Check this box if there is a post-accident drug testing policy in place. Fill only if 'Has the applicant entered into any written contractual agreements to perform ambulance service for a
government entity, hospital, or nursing home?' is 'Yes'.
Depends on:
Yes
|
| No | Radiobutton |
Check this box if there is no post-accident drug testing policy in place. Fill only if 'Has the applicant entered into any written contractual agreements to perform ambulance service for a
government entity, hospital, or nursing home?' is 'Yes'.
Depends on:
Yes
|
| Post-Trip Vehicle Inspections Status | ||
| Yes | Radiobutton |
Check this box if the applicant regularly performs post-trip vehicle inspections. Fill only if 'Has the applicant entered into any written contractual agreements to perform ambulance service for a
government entity, hospital, or nursing home?' is 'Yes'.
Depends on:
Yes
|
| No | Radiobutton |
Check this box if the applicant does not regularly perform post-trip vehicle inspections. Fill only if 'Has the applicant entered into any written contractual agreements to perform ambulance service for a
government entity, hospital, or nursing home?' is 'Yes'.
Depends on:
Yes
|
| Pre-established Criteria Usage | ||
| Yes | Radiobutton |
Check this box if pre-established criteria are used when reviewing Motor Vehicle Records (MVRs). Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| No | Radiobutton |
Check this box if pre-established criteria are not used when reviewing Motor Vehicle Records (MVRs). Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Pre-Trip Vehicle Inspections Status | ||
| Pre-Trip Inspections Yes | Radiobutton |
Check this box if the applicant regularly performs pre-trip vehicle inspections. Fill only if 'Has the applicant entered into any written contractual agreements to perform ambulance service for a
government entity, hospital, or nursing home?' is 'Yes'.
Depends on:
Yes
|
| Pre-Trip Inspections No | Radiobutton |
Check this box if the applicant does not regularly perform pre-trip vehicle inspections. Fill only if 'Has the applicant entered into any written contractual agreements to perform ambulance service for a
government entity, hospital, or nursing home?' is 'Yes'.
Depends on:
Yes
|
| Prior Losses Details | ||
| Yes | Radiobutton |
Check this box if there have been any losses in the prior five (5) years.
|
| No | Radiobutton |
Check this box if there have been no losses in the prior five (5) years.
|
| Prior Losses Details | Text |
Provide full details regarding any losses that occurred in the prior five years. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Procedures for Pre-Employment Selection of Drivers | ||
| Written Application | CheckBox | |
| Criminal Background Check | CheckBox | |
| Pre-employment Drug Testing | CheckBox | |
| Physical Examination | CheckBox | |
| Written Driving Exam | CheckBox | |
| Road Test | CheckBox | |
| Motor Vehicle Record Check | CheckBox | |
| References Check | CheckBox | |
| Physical Abilities Test | CheckBox | |
| Progressive Discipline Policy Status | ||
| Yes | Radiobutton |
Check this box if there is a progressive discipline policy for drivers involved in serious or multiple accidents/violations. Fill only if 'Has the applicant entered into any written contractual agreements to perform ambulance service for a
government entity, hospital, or nursing home?' is 'Yes'.
Depends on:
Yes
|
| No | Radiobutton |
Check this box if there is no progressive discipline policy for drivers involved in serious or multiple accidents/violations. Fill only if 'Has the applicant entered into any written contractual agreements to perform ambulance service for a
government entity, hospital, or nursing home?' is 'Yes'.
Depends on:
Yes
|
| Radius of Operation | ||
| Radius of Operation | Number |
Please provide the applicant's radius of operation.
|
| Random Drug and Alcohol Testing Status | ||
| Yes | Radiobutton |
Check this box if drivers are subject to random drug and alcohol testing. Fill only if 'Has the applicant entered into any written contractual agreements to perform ambulance service for a
government entity, hospital, or nursing home?' is 'Yes'.
Depends on:
Yes
|
| No | Radiobutton |
Check this box if drivers are not subject to random drug and alcohol testing. Fill only if 'Has the applicant entered into any written contractual agreements to perform ambulance service for a
government entity, hospital, or nursing home?' is 'Yes'.
Depends on:
Yes
|
| Restraint System Design | ||
| Yes | Radiobutton |
Check this box if all restraint systems are designed with a "4-point tie-down" and "forward facing" features.
|
| No | Radiobutton |
Check this box if not all restraint systems are designed with a "4-point tie-down" and "forward facing" features.
|
| Safety Restraints on Stretchers | ||
| Yes | Radiobutton |
Check this box if the applicant uses knee, hip, chest, and over the shoulder safety restraints on stretchers.
|
| No | Radiobutton |
Check this box if the applicant does not use knee, hip, chest, and over the shoulder safety restraints on stretchers.
|
| Salvaged Vehicles Status | ||
| Yes | Radiobutton |
Check this box if the insured has salvaged vehicles in their fleet. Fill only if 'Has the applicant entered into any written contractual agreements to perform ambulance service for a
government entity, hospital, or nursing home?' is 'Yes'.
Depends on:
Yes
|
| No | Radiobutton |
Check this box if the insured does not have salvaged vehicles in their fleet. Fill only if 'Has the applicant entered into any written contractual agreements to perform ambulance service for a
government entity, hospital, or nursing home?' is 'Yes'.
Depends on:
Yes
|
| Scooter Chair Transfer Requirement | ||
| Yes | Radiobutton |
Check this box if passengers in scooter type chairs are required to transfer to a wheelchair or a permanent seat after loading. Fill only if 'Tri-Wheeler/Scooter' is 'Yes'.
Depends on:
Tri-Wheeler/Scooter
|
| No | Radiobutton |
Check this box if passengers in scooter type chairs are not required to transfer to a wheelchair or a permanent seat after loading. Fill only if 'Tri-Wheeler/Scooter' is 'Yes'.
Depends on:
Tri-Wheeler/Scooter
|
| Second Auto Liability Insurance Coverage | ||
| Occurrence | Checkbox |
Check this box if the second auto liability insurance policy is an 'Occurrence' type policy.
|
| Second Auto Policy Company | Text |
Enter the name of the insurance company for the second auto liability policy.
|
| Second Auto Policy Period | Text |
Enter the policy period for the second auto liability policy.
|
| Second Auto Limits of Liability Per Occurrence | Number |
Enter the per occurrence limit of liability for the second auto liability policy.
|
| Second Auto Limits of Liability Aggregate | Number |
Enter the aggregate limit of liability for the second auto liability policy.
|
| Second Auto Retention/Deductible Aggregate | Number |
Enter the aggregate retention or deductible amount for the second auto liability policy.
|
| Second Auto Retention/Deductible Per Occurrence | Number |
Enter the per occurrence retention or deductible amount for the second auto liability policy.
|
| Second Auto Policy Premium | Number |
Enter the premium amount for the second auto liability policy.
|
| Second General Liability Insurance Coverage | ||
| Claims-Made | Checkbox |
This box should be checked if the general liability insurance policy is a claims-made policy.
|
| Occurrence | Checkbox |
This box should be checked if the general liability insurance policy is an occurrence-based policy.
|
| Second Company Name | Text |
Enter the name of the insurance company for the second general liability coverage entry.
|
| Second Limits of Liability Amount 1 | Number |
Provide the first monetary limit of liability for the second general liability insurance coverage entry.
|
| Second Limits of Liability Amount 2 | Number |
Provide the second monetary limit of liability for the second general liability insurance coverage entry. Fill only if 'Second Company Name' is not empty.
|
| Second Retention Deductible Amount 2 | Number |
Enter the second monetary retention or deductible amount for the second general liability insurance coverage entry.
|
| Second Retention Deductible Amount 1 | Number |
Enter the first monetary retention or deductible amount for the second general liability insurance coverage entry.
|
| Second Premium Amount | Number |
Enter the premium amount for the second general liability insurance coverage entry.
|
| Second Retro Date | Date |
Provide the retro date for the second general liability insurance coverage entry. Fill only if 'Claims-Made' is 'Yes'.
Depends on:
Claims-Made
|
| Second Prior Policy Information | ||
| Second Prior Vehicle Count | Number |
Please enter the vehicle count for the second prior policy.
|
| Second Prior Number of Transports | Number |
Please enter the number of transports for the second prior policy.
|
| Second Professional Liability Insurance Coverage | ||
| Claims-Made | Checkbox |
Check this box if the second professional liability insurance coverage is a claims-made policy.
|
| Occurrence | Checkbox |
Check this box if the second professional liability insurance coverage is an occurrence policy.
|
| Second Coverage Company Name | Text |
Enter the name of the insurance company for the second professional liability coverage listed.
|
| Second Coverage Policy Period | Text |
Enter the policy period for the second professional liability coverage listed.
|
| Second Coverage Limits Per Occurrence | Number |
Enter the per occurrence or per claim limit of liability for the second professional liability coverage listed.
|
| Second Coverage Limits Aggregate | Number |
Enter the aggregate limit of liability for the second professional liability coverage listed.
|
| Second Coverage Deductible Amount | Number |
Enter the deductible amount for the second professional liability coverage listed.
|
| Second Coverage Retention Amount | Number |
Enter the retention amount for the second professional liability coverage listed.
|
| Second Coverage Premium | Number |
Enter the total premium amount for the second professional liability coverage listed.
|
| Second Coverage Retro Date | Date |
Enter the retroactive date for the second professional liability coverage listed. Fill only if 'Claims-Made' is 'Yes'.
Depends on:
Claims-Made
|
| Service Level Percentage | ||
| Curb-to-Curb Percentage | Number |
Please provide the percentage of trips that are Curb-to-Curb.
|
| Door-to-Door Percentage | Number |
Please provide the percentage of trips that are Door-to-Door.
|
| Door-through-Door Percentage | Number |
Please provide the percentage of trips that are Door-through-Door.
|
| State/Federal Filings Requirement and Details | ||
| Permit Numbers and States | Text |
Please provide the permit numbers and corresponding states for any required filings. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Yes | Radiobutton |
Check this box if state and/or federal filings are required for the applicant.
|
| No | Radiobutton |
Check this box if no state and/or federal filings are required for the applicant.
|
| Subsidiary Status and Explanation | ||
| Subsidiary Explanation | Text |
Provide an explanation if your service is a subsidiary of another company. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Yes | Radiobutton |
Check this box if your service is a subsidiary of another company.
|
| No | Radiobutton |
Check this box if your service is not a subsidiary of another company.
|
| Third Auto Liability Insurance Coverage | ||
| Occurrence | Checkbox |
Check this box if the third auto liability insurance coverage provided is an Occurrence policy.
|
| Third Policy Period | Text |
Enter the policy period for the third year of auto liability coverage.
|
| Third Company | Text |
Enter the name of the insurance company for the third year of auto liability coverage.
|
| Third Limits of Liability (Individual) | Number |
Enter the individual limits of liability for the third year of auto liability coverage.
|
| Third Limits of Liability (Aggregate) | Number |
Enter the aggregate limits of liability for the third year of auto liability coverage.
|
| Third Retention/Deductible (Aggregate) | Number |
Enter the aggregate retention or deductible amount for the third year of auto liability coverage.
|
| Third Retention/Deductible (Individual) | Number |
Enter the individual retention or deductible amount for the third year of auto liability coverage.
|
| Third Premium | Number |
Enter the premium amount for the third year of auto liability coverage.
|
| Third General Liability Insurance Coverage | ||
| Claims-Made | Checkbox |
Check this box if the third general liability insurance policy was a claims-made policy.
|
| Occurrence | Checkbox |
Check this box if the third general liability insurance policy was an occurrence-based policy.
|
| Premium | Number |
Enter the annual premium for this general liability policy.
|
| Company Name | Text |
Enter the name of the insurance company for this general liability policy.
|
| Limits of Liability - Per Occurrence | Number |
Enter the per-occurrence limit of liability for this general liability policy.
|
| Limits of Liability - Aggregate | Number |
Enter the aggregate limit of liability for this general liability policy.
|
| Retention/Deductible - Aggregate | Number |
Enter the aggregate retention or deductible amount for this general liability policy.
|
| Retention/Deductible - Per Occurrence | Number |
Enter the per-occurrence retention or deductible amount for this general liability policy.
|
| Retro Date | Date |
Enter the retro date for this claims-made general liability policy. Fill only if 'Claims-Made' is 'Yes'.
Depends on:
Claims-Made
|
| Third Prior Policy Information | ||
| Third Prior Vehicle Count | Number |
Enter the total number of vehicles for the third prior policy.
|
| Third Prior Number of Transports | Number |
Enter the total number of transports for the third prior policy.
|
| Third Professional Liability Insurance Coverage | ||
| Claims-Made | Checkbox |
Check this box if the third professional liability insurance policy is a claims-made type of coverage.
|
| Occurrence | Checkbox |
Check this box if the third professional liability insurance policy is an occurrence type of coverage.
|
| Third Policy Period | Text |
Provide the policy period for the third professional liability insurance coverage.
|
| Third Company Name | Text |
Enter the name of the company providing the third professional liability insurance coverage.
|
| Third Per Claim Limit | Number |
Enter the per claim limit of liability for the third professional liability insurance coverage.
|
| Third Aggregate Limit | Number |
Enter the aggregate limit of liability for the third professional liability insurance coverage.
|
| Third Aggregate Retention/Deductible | Number |
Enter the aggregate retention or deductible amount for the third professional liability insurance coverage.
|
| Third Per Claim Retention/Deductible | Number |
Enter the per claim retention or deductible amount for the third professional liability insurance coverage.
|
| Third Premium | Number |
Enter the premium amount for the third professional liability insurance coverage.
|
| Third Retro Date | Date |
Provide the retro date for the third professional liability insurance coverage. Fill only if 'Claims-Made' is 'Yes'.
Depends on:
Claims-Made
|
| Training for Loading and Unloading Clients | ||
| Training Description | Text |
Provide a description of the training provided to employees for loading and unloading clients. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Training Provider Verification | ||
| Yes | Radiobutton |
Check this box if the training is provided by a Medical Professional and/or Medical Director.
|
| No | Radiobutton |
Check this box if the training is not provided by a Medical Professional and/or Medical Director.
|
| Transport Without Restraint System | ||
| Yes | Radiobutton |
Check this box if wheelchair passengers are ever transported without the use of a restraint system.
|
| No | Radiobutton |
Check this box if wheelchair passengers are never transported without the use of a restraint system.
|
| Trip Category Percentage | ||
| Wheelchair Percentage | Number |
Enter the percentage of trips that fall into the wheelchair category.
|
| Stretcher Percentage | Number |
Enter the percentage of trips that fall into the stretcher category.
|
| Passenger Percentage | Number |
Enter the percentage of trips that fall into the passenger category.
|
| Trip Scheduling Percentage | ||
| Prescheduled Percentage | Number |
Enter the percentage of trips that are prescheduled.
|
| On-Demand Percentage | Number |
Enter the percentage of trips that are on-demand.
|
| Emergency Percentage | Number |
Enter the percentage of trips that are for emergency services.
|
| Type of Service | ||
| Ambulance | Checkbox |
Check this box if the service provided is ambulance service.
|
| Paramedic | Checkbox |
Check this box if the service provided is paramedic service.
|
| Adult Day Care | Checkbox |
Check this box if the service provided is adult day care.
|
| Social Service Organizations Transportation | Checkbox |
Check this box if the service provided is transportation for social service organizations.
|
| Rescue Squad with Ambulance | Checkbox |
Check this box if the service provided is rescue squad service that includes an ambulance.
|
| Fire Department with Ambulance | Checkbox |
Check this box if the service provided is fire department service that includes an ambulance.
|
| Individual EMT | Checkbox |
Check this box if the service provided is by an individual Emergency Medical Technician (EMT).
|
| Dispatch Service for Others | Checkbox |
Check this box if the service provided is dispatch service for other entities or individuals.
|
| First Responder | Checkbox |
Check this box if the service provided is first responder service.
|
| Psychiatric | Checkbox |
Check this box if the service provided is psychiatric care or transportation.
|
| Taxi/Limo/General Transportation Service | Checkbox |
Check this box if the service provided is taxi, limousine, or general transportation.
|
| Non-Emergency Medical | Checkbox |
Check this box if the service provided is non-emergency medical transport or care.
|
| Alarm Monitoring | Checkbox |
Check this box if the service provided includes alarm monitoring.
|
| School Transportation | Checkbox |
Check this box if the service provided is school transportation.
|
| Special Needs Transportation | Checkbox |
Check this box if the service provided is transportation for individuals with special needs.
|
| Rescue Squad without Ambulance | Checkbox |
Check this box if the service provided is rescue squad service that does not include an ambulance.
|
| Fire Department without Ambulance | Checkbox |
Check this box if the service provided is fire department service that does not include an ambulance.
|
| Individual Paramedic | Checkbox |
Check this box if the service provided is by an individual paramedic.
|
| Air Ambulance | Checkbox |
Check this box if the service provided is air ambulance service.
|
| Off Shore EMT | Checkbox |
Check this box if the service provided is by an off-shore Emergency Medical Technician (EMT).
|
| Incarcerated | Checkbox |
Check this box if the service provided involves incarcerated individuals.
|
| Other | Checkbox |
Check this box if the type of service provided is not listed among the other options.
|
| Other Service Type | Text |
Please provide the type of service if it is not listed among the provided options. Fill only if 'Other' is 'Yes'.
Depends on:
Other
|
| Types of Stretchers Used | ||
| Types of Stretchers Used | Text |
Please provide the types of stretchers used in the vehicles.
|
| Vehicle Borrowing Inquiry | ||
| Borrow Vehicles - Yes | Radiobutton |
Check this box if the applicant leases, hires, or borrows vehicles from others.
|
| Borrow Vehicles - No | Radiobutton |
Check this box if the applicant does not lease, hire, or borrow vehicles from others.
|
| Vehicle Cameras or Accident Event Recorders | ||
| Yes | Radiobutton |
Check this box if the vehicles are equipped with cameras or accident event recorders. Fill only if 'Has the applicant entered into any written contractual agreements to perform ambulance service for a
government entity, hospital, or nursing home?' is 'Yes'.
Depends on:
Yes
|
| No | Radiobutton |
Check this box if the vehicles are not equipped with cameras or accident event recorders. Fill only if 'Has the applicant entered into any written contractual agreements to perform ambulance service for a
government entity, hospital, or nursing home?' is 'Yes'.
Depends on:
Yes
|
| Vehicle Count by Type | ||
| Operational Ambulances Count | Number |
Enter the total number of operational ambulances the applicant currently operates.
|
| Standby Ambulances Count | Number |
Enter the total number of standby ambulances the applicant currently operates.
|
| Buses Count | Number |
Enter the total number of buses the applicant currently operates.
|
| Vans/Mini Vans/Ambulettes Count | Number |
Enter the total number of vans, mini vans, or ambulettes the applicant currently operates.
|
| Passenger Cars Count | Number |
Enter the total number of passenger cars the applicant currently operates.
|
| Other Vehicle Type Count | Number |
Enter the total number of other specified vehicles the applicant currently operates.
|
| Vehicle Defect and Repair Records Inquiry | ||
| Maintain Records of Defects and Repairs - Yes | Radiobutton |
Check this box if the applicant maintains records listing vehicle defects and repairs.
|
| Maintain Records of Defects and Repairs - No | Radiobutton |
Check this box if the applicant does not maintain records listing vehicle defects and repairs.
|
| Vehicle Loaning Inquiry | ||
| Yes | Radiobutton |
Check this box if the applicant leases, hires out, or loans vehicles to others.
|
| No | Radiobutton |
Check this box if the applicant does not lease, hire out, or loan vehicles to others.
|
| Vehicle Storage Information | ||
| Storage Location After Hours | Text |
Please provide the location where vehicles are stored after hours.
|
| Storage Provisions | Text |
Please describe the provisions made for vehicles when they are stored.
|
| Yes | Radiobutton |
Check this box if all vehicles are garaged in the same location.
|
| No | Radiobutton |
Check this box if not all vehicles are garaged in the same location.
|
| Vehicle Titling and Licensing Inquiry | ||
| Yes | Radiobutton |
Check this box if all vehicles are titled and licensed to the first named insured.
|
| No | Radiobutton |
Check this box if not all vehicles are titled and licensed to the first named insured.
|
| Volunteer/Contracted Driver Qualifications | ||
| Yes | Radiobutton |
Check this box if the applicant's volunteer or contracted drivers are subject to all of the same qualifications as full-time and part-time drivers.
|
| No | Radiobutton |
Check this box if the applicant's volunteer or contracted drivers are NOT subject to all of the same qualifications as full-time and part-time drivers.
|
| Website | ||
| Website | Text |
Provide the website address for the entity.
|
| Weekend Service Availability | ||
| Weekend Service Provided | Text |
Indicate whether the applicant provides service during weekends.
|
| Wheelchair Security Method | ||
| Fixed Access Locations | Checkbox |
Check this box if wheelchairs are secured to the floor of the vehicle using fixed access locations.
|
| Moveable Attachments | Checkbox |
Check this box if wheelchairs are secured to the floor of the vehicle using moveable attachments.
|
| Both | Radiobutton |
Check this box if wheelchairs are secured to the floor of the vehicle using both fixed access locations and moveable attachments.
|
| Written Driver Criteria | ||
| Yes | Radiobutton |
Check this box if the applicant has written driver criteria in place.
|
| No | Radiobutton |
Check this box if the applicant does not have written driver criteria in place.
|
| Written Safety Program | ||
| Program Duration | Text |
Specify the duration (e.g., in years or months) for which the written safety program procedures have been in place. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Yes | Radiobutton |
Check this box if the applicant has a written safety program in place. Fill only if 'Has the applicant entered into any written contractual agreements to perform ambulance service for a
government entity, hospital, or nursing home?' is 'Yes'.
Depends on:
Yes
|
| No | Radiobutton |
Check this box if the applicant does not have a written safety program in place. Fill only if 'Has the applicant entered into any written contractual agreements to perform ambulance service for a
government entity, hospital, or nursing home?' is 'Yes'.
Depends on:
Yes
|
| Written Vehicle Maintenance Program Inquiry | ||
| Written Program - Yes | Radiobutton |
Check this box if the applicant utilizes a written vehicle maintenance program.
|
| Written Program - No | Radiobutton |
Check this box if the applicant does not utilize a written vehicle maintenance program.
|
| Years Under Current Insurance Agency | ||
| Years with Current Insurance Agency | Number |
Provide the number of years the entity has been with its current insurance agency.
|
| Years Under Current Management | ||
| Years Under Current Management | Number |
Provide the total number of years the entity has been operating under its current management.
|