Home Programs Physical Therapy Application Form

Application Form

PT1 Insurance Solutions

Home Programs Physical Therapy Application Form

Apply Online

COMPLETE OUR EASY APPLICATION ONLINE AND OUR TEAM WILL BE IN TOUCH WITH YOU!

PT1 Insurance Solutions Application

DOWNLOAD PDF APPLICATION

Contact Information
Applicant Name (including DBAs)
FEIN or Social Security Number
Mailing Address
Mailing Zip
Mailing City
Mailing State
- - Location Address
  - Location Zip
  - Location City
  - Location State
  - County (parish)
Office Phone
Office Fax
Person to Contact for Survey
Contact Name
Contact Title
Contact Email
I would also like to receive a competitive quote for the following:
- Property
- Workers' Compensation
- Cyber/Data Breach Liability
- Business Auto
- Employment Practices Liability
- Directors and Officers
Number of estimated client contacts
- Next 12 months
- Last 12 months
Annual Gross Receipts
- Estimated next 12 months $
- Last 12 months $
Total Annual Payroll
- Estimated next 12 months $
- Last 12 months $
Entity is
Individual
Partnership
Other

If Other, please describe.
Corporation
Professional Association/Corporation
Year entity established
Are you affiliated with a national or regional network or association?
Yes No
If YES, please indicate all applicable in order to verify eligible programs.
Please describe in detail any additional operations, business pursuits, joint ventures in which your facility is currently engaged that would fall outside the scope of typical physical therapy operations?
Yes No
If yes, please describe in detail.
How many years have you been under the same ownership?
How many years of experience do you have in the rehab industry?
Indicate each treatment modality used by the applicant.

Short Wave Diathermy

Electrical Stimulation

Galvanic

Ultraviolet

Other If Other, please describe.
Mobile Equipment If Mobile Equipment, please describe.

Ultrasound

Mechanical Traction

Whirlpool
Are employees that lift clients or assist clients in weight-bearing movements required to wear back support?
Yes No
Do you have procedures in place for the handling of your larger clients?
Yes No
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?
Yes No
Do you require an official release from the emergency room or PCP prior to the employee returning to work?
Yes No
Does applicant provide physical therapy services only as prescribed by a physician?
Yes No

If NO, explain exceptions.
Do you keep daily work reports on all patients as they are seen?
Yes No
Approximately what percentage of applicant’s patients are:

a) under the age of 18? %

b) over the age of 18? %
Approximately what percentage of applicant’s practice is associated with sports injuries? %
Has applicant treated any professional or collegiate athletes?
Yes No
If YES, how many in the past year?
Are any tests conducted/results interpreted or diagnosed by applicant?
Yes No

IF YES, describe including who the results are sent to and on whose letterhead results are shown.
How many employees/independent contractors do you employ in each of the following positions:
- Physical Therapists
- Occupational Therapists
- Massage Therapists
- Physical Therapy Assistants
- Speech Therapists
- Physician/Physician Assistants
All others (describe)
What operating system, e.g., Windows 7,8,etc.,do you use?
How often do you perform system updates?
Do you use firewall technology?
Yes No
Do you use anti-virus software?
Yes No
If yes, is anti-virus software installed on all of your employees (used for business) computer systems, including laptops, personal computers and networks?
Yes No
Do you use intrusion detection software to detect unauthorized access to internal networks and computer systems?
Yes No
Is it your policy to upgrade all security software as new releases or improvements become available?
Yes No
Do you provide remote access to its network?
Yes No
Is remote access restricted to Virtual Private Networks (VPNs)?
Yes No
Do you have written screening and hiring policies and procedures for all prospective employees, students, independent contractors/consultants and volunteers?
Yes No
Are there written guidelines regarding sexual misconduct or physical abuse?
Yes No
Do you perform criminal background checks as part of your employee screening process?
Yes No
Have you had any incidents or claims reported for sexual misconduct or any other allegation of abuse?
Yes No
If yes, provide full details.
Have you or any of your employees:
a) Ever been the subject of disciplinary or investigatory proceedings or reprimanded by an administrative or governmental agency, hospital or professional association?
Yes No
b)Had any professional license refused, suspended, revoked, renewal refused or accepted only with special terms or have you or any of your employees voluntarily surrendered any professional license?
Yes No
c) Been convicted for an act committed in violation of any law or ordinance other than traffic offenses?
Yes No
Do you have a formal risk management procedure in place?
Yes No
If yes, who is responsible and what is his/her job title?
IF THE ANSWER TO ANY OF THE ABOVE IS YES, PLEASE ATTACH A DETAILED EXPLANATION.
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?
Yes No
If yes, please describe, indicate status of the claim or suit, and any amount(s) paid or reserved (attach an additional sheet if necessary).
Does any proposed insured have any knowledge of an event, circumstance or occurrence (other than any listed in #26 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?
Yes No
If yes, describe the event and indicate the reason for anticipation of a claim
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?
Yes No
Attach an additional document here.
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 VGM Group, 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.
Date
Applicant/Title

Application Form

PT1 Insurance Solutions

Apply Online

COMPLETE OUR EASY APPLICATION ONLINE AND OUR TEAM WILL BE IN TOUCH WITH YOU!

PT1 Insurance Solutions Application

Contact Information

Person to Contact for Survey

Entity is

Are you affiliated with a national or regional network or association?

Please describe in detail any additional operations, business pursuits, joint ventures in which your facility is currently engaged that would fall outside the scope of typical physical therapy operations?

Indicate each treatment modality used by the applicant.

Are employees that lift clients or assist clients in weight-bearing movements required to wear back support?

Do you have procedures in place for the handling of your larger clients?

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?

Do you require an official release from the emergency room or PCP prior to the employee returning to work?

Does applicant provide physical therapy services only as prescribed by a physician?

Do you keep daily work reports on all patients as they are seen?

Approximately what percentage of applicant’s patients are:

Has applicant treated any professional or collegiate athletes?

Are any tests conducted/results interpreted or diagnosed by applicant?

How many employees/independent contractors do you employ in each of the following positions:

Do you use firewall technology?

Do you use anti-virus software?

If yes, is anti-virus software installed on all of your employees (used for business) computer systems, including laptops, personal computers and networks?

Do you use intrusion detection software to detect unauthorized access to internal networks and computer systems?

Is it your policy to upgrade all security software as new releases or improvements become available?

Do you provide remote access to its network?

Is remote access restricted to Virtual Private Networks (VPNs)?

Do you 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?

Have you had any incidents or claims reported for sexual misconduct or any other allegation of abuse?

Have you or any of your 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 have you or any of your employees voluntarily surrendered any professional license?

c) Been convicted for an act committed in violation of any law or ordinance other than traffic offenses?

Do you have a formal risk management procedure in place?

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?

Does any proposed insured have any knowledge of an event, circumstance or occurrence (other than any listed in #26 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?

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?

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