HOME HEALTH LIABILITY INSURANCE & BONDING 
Download A Paper Application
Need Assistance?  Call Jason Miller at
800-866-2682, Ext. 101
SECTION I - APPLICANT INFORMATION
Full Corporate Name:
SECTION II - OPERATIONS
Type of Business (Check All That Apply)



Do you rent, sell or service any products:
If yes, please indicate total revenue attributable to products:

Do you perform criminal background checks on all employees?

Years in business under this name?

Gross revenue for the past 12 months:

Gross revenue estimated for the next 12 months:

Do you provide services in any of the following areas?  If so, please note what % of total revenue is attributable to that service:







SECTION III - GENERAL UNDERWRITING INFORMATION
Desired Effective Date:

Are you currently insured for General & Professional Liability?

If yes, please complete the following, or fax (or e-mail) a current certificate to Jason Miller, 866-847-7232 (jason@solg.net)

1) Name of Insurance Company

2) Coverage Form:  

3) Retroactive Date:

4) Limits of Insurance:

5) Current Premium: 

Have any claims/suits been made within the last 5 years against the applicant?
If yes, please include information below specifying the date, description, amount paid and amount reserved.

Is the applicant aware of any circumstances which may result in any claim or suit being made, including 
requests for medical records?
If yes, please include information below specifying the date, description, amount paid and amount reserved.

Has any insurance company declined, cancelled, or refused to renew any of the applicant's insurance?
If yes, please include information below describing why coverage was denied or cancelled.
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(Required Field)
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State
Company Address:
City:
Zip:
Entity Type:
Federal Employer Identification Number (FEIN):
Telephone:
Fax:
E-Mail:
Contact Name:
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Trustpilot
Franchise or Membership Group?
CorporationLLCPartnershipSole ProprietorshipNot Yet DeterminedOther
Home Health
Non-Medical Home Care
Medical Staffing
Outpatient Clinic
Nurse Registry
Other:
YesNo
YesNo
Nursing Home or Assisted Living Facility
I.V. Therapy
Trach
Ventilator
Clinics
Prisons
Pediatric
High-tech / Critical / Surgical
Hospitals
Physician Office
YesNo
Claims-MadeOccurrenceI Don't Know
YesNo
YesNo
YesNo