This application must be completed in conjunction with the Allied Healthcare Facilities Common Application.

INSTRUCTIONS

1. Please read the instructions carefully. Complete and submit all requested information and/or required attachments

This application and all materials submitted shall be held in confidence.

2. All application questions must be fully answered. If a question does not apply, please write “N/A”.

3. If you need more space, continue on a separate sheet of your letterhead and indicate the question number.

1. Name of Applicant: _______________________________________________________________________________________

2. Type of Facility (check all that apply):

Free Standing Provider Based (unit of hospital, nursing home, or home health agency)

Critical Access Hospital Based Other: List _____________________________________________________________

3. What population do you service (%)?

Elderly ______% School Based ______% Migrant ______% Homeless ______%

Other ______% (Describe) _______________________________________________________________________________

4. Current Number of Patients: ______

a. Typical % of pediatric patients ______%

b. Typical % of adult patients ______%

5. Is the Applicant deemed under the Federal Tort Claims Act? Yes No

If So, please provide the following:

a. A copy of the most recent FTCA application for Medical/Dental Professional Liability

Protection. Form 5 Parts A-C, Original Deeming Letter, and Uniform Data System

(UDS) Report.

b. FTCA initial deeming date: __________ Deeming end date: __________

c. Are any sites at which services are provided operated by a sub-recipient or contractor? Yes No

i. If Yes, are all deemed services and deemed locations? Yes No

ii. If Not, please explain: _____________________________________________________________________________

d. Does the Applicant require individuals not covered by the FTCA to carry

Professional Liability Insurance? Yes No

i. If Yes, indicate the minimum professional liability limits required:

$_________________ each claim/ $_________________ aggregate

ii. If No, please complete Roster Addendum

S U P P L E M E N T A L A P P L I C A T I O N

Community Health Center

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e. Do interns/medical residents or others provide primary care rotations at the Applicant’s

health center? Yes No

i. If Yes, is the training covered by the FTCA deeming letter? Yes No

ii. If the training is not covered by the FTCA deeming letter, what entity

is responsible for providing insurance coverage?

Applicant Medical School Other: _______________________________________________________

iii. If training is provided by the applicant, do you want coverage to include

interns/medical residents Yes No

If Yes, please provide the average number of FTEs per week ______

f. Does the Applicant require volunteers to carry Professional Liability Insurance? Yes No

i. If Yes, indicate the minimum professional liability limits required:

$_________________ each claim/ $_________________ aggregate

ii. If No, please complete Roster Addendum

6. Do you arrange with local community providers to provide after-hours coverage

to your patients? Yes No

a. If Yes, is this arrangement approved within Scope? Yes No

b. If the arrangement is not approved within Scope, do you require the other entity

and providers to maintain insurance? Yes No

7. Indicate % of Gross Receipts by Type of Care and Visits. “Visits” are defined as the number of patients entering the

facility for health related services per year.

Services Provided % of Gross Receipts

Projected Annual Number of Deemed

Visits/Revenue as noted

Projected Annual Number of

Non-deemed Visits/Revenue as noted

Adult Primary Health Care # of visits – # of visits –

Behavioral Health — indicate number of visits in sections below

Substance Abuse Counseling # of visits – # of visits –

Mental Health Counseling # of visits – # of visits –

Chronic Disease Management, e.g. asthma, obesity, diabetes # of visits – # of visits –

Clinical Trials Revenues: Revenues:

Dental Care # of visits – # of visits –

Emergency/Urgent Care # of visits – # of visits –

Eye Care # of visits – # of visits –

Food Bank/Meals # of meals – # of meals –

Health Fair — Adult Immunizations # of visits – # of visits –

Home Health Care # of visits – # of visits –

Imaging Services Revenues: Revenues:

Immunizations, including tetanus, diphtheria, and influenza # of visits – # of visits –

Insurance Eligibility Screening # of visits – # of visits –

Invasive Procedures (please describe) # of visits – # of visits –

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Services Provided % of Gross Receipts

Projected Annual Number of Deemed

Visits/Revenue as noted

Projected Annual Number of

Non-deemed Visits/Revenue as noted

Laboratory Testing Revenues: Revenues:

Medical Referral Services # of visits – # of visits –

Medical Social Services # of visits – # of visits –

Methadone Dispensing # of visits – # of visits –

Nutritional Counseling # of visits – # of visits –

Pediatric Primary Care # of visits – # of visits –

Pharmacy Revenues: Revenues:

Pre-employment physical exams # of visits – # of visits –

Social Services # of visits – # of visits –

TB Testing # of visits – # of visits –

Women’s Health Care — Indicate by sections below

Abortions # of visits – # of visits –

Breast examination # of visits – # of visits –

Dilatation and Curettage # of visits – # of visits –

Family planning services # of visits – # of visits –

Mammography Referral # of visits – # of visits –

Obstetrical Deliveries # of visits – # of visits –

Post-partum care # of visits – # of visits –

Prenatal care # of visits – # of visits –

Other: # of visits – # of visits –

8. Staffing:

Personnel by category Employees/

Contractors

working more

than 32.5

hours per week

(DEEMED)

Specialty

Providers (as

defined by the

FTCA) working

less than 32.5

hours per week

(DEEMED)

Employees

(Non-deemed)

Contractors

(Non-deemed)

Volunteers

Medical/Clinical Directors

Family Practice Physicians

Internal Medicine Physicians

OB/GYNs

Pediatricians

Other Specialty Physicians

(please describe)

Physician Assistants

Nurse Practitioners

Certified Nurse Midwives

Pharmacists

Dentists/Oral

126-0117 (6/14)

hanover.com

The Hanover Insurance Company | 440 Lincoln Street, Worcester, MA 01653

PAGE 4

Personnel by category Employees/

Contractors

working more

than 32.5

hours per week

(DEEMED)

Specialty

Providers (as

defined by the

FTCA) working

less than 32.5

hours per week

(DEEMED)

Employees

(Non-deemed)

Contractors

(Non-deemed)

Volunteers

Psychiatrists

Psychologists

Other Licensed Independent

Professionals (please describe)

9. Do you use volunteers? Yes No

If Yes, what type of services do they provide? ________________________________________________________________

If Yes, do all volunteers undergo a criminal background check? Yes No

10. Do you operate a Pharmacy? Yes No

a. If Yes, Receipts $_________________

b. If the Applicant is a distributor are the prescriptions: pre-packaged, or compound mixture

c. Is the Applicant: packaging, compounding, or performing admixture?

d. Does the pharmacy compound medications? Yes No

e. Does the pharmacy dispense controlled narcotics? Yes No