Host Home Program Online Insurance Application

Annual Host Home Program Pricing

March 2026 - 2027

Premiums Ages 18-64:

1 Client $452.18 - Includes $13.15 in Surplus Lines Tax and $0.77 in Surplus Lines Processing Fees
2 Clients $823.40 - Includes $23.47 in Surplus Lines Tax and $1.37 in Surplus Lines Processing Fees
3 Clients $1,153.78 - Includes $33.55 in Surplus Lines Tax and $1.96 in Surplus Lines Processing Fees

Premiums Ages 65+:

1 Client $588.62- Includes $17.12 in Surplus Lines Tax and $1.00 in Surplus Lines Processing Fees
2 Clients $944.74 - Includes $27.47 in Surplus Lines Tax and $1.60 in Surplus Lines Processing Fees
3 Clients $1,290.26 - Includes $37.52 in Surplus Lines Tax and $2.19 in Surplus Lines Processing Fees

Please complete all the information in the Online Application. Should you have any questions, feel free to contact us.

"*" indicates required fields

Step 1 of 4

25%

Section 1: General Information

This field is hidden when viewing the form

Application Year

Are you new to the Care Association?*

I am Renewing

I am New

I am not sure

Full Name (not your consumer):*

Trade Name (If applicable):

Do you pay Respite Workers, and do they have their own insurance?

Yes

Please be aware, if you have a paid respite worker, your Host Home Insurance coverage does not extend to that provider.

Home Address

Street Address City State ZIP Code

Home/Cell Phone Number*

Email Address: (if you have one)

Is Your Home Address the same as your Host Home Address: (If not please put in the address of the Host Home)*

Yes

Host Home Address*

Street Address City State ZIP Code

List all Agencies that you are contracted with for your Host Home:*

Primary Agencies phone number if you have it:

Section 2: Underwriting Questions

General Information Questions

1. Are your clients developmentally disabled?*

Yes

All clients living in your home MUST be DEVELOPMENTALLY DISABLED. Please contact our office at 303-333-0375 for details. Due to the nature of this answer, this application cannot be processed online.

2. Are you providing services for 'non-developmentally disabled' individuals, i.e. At-Risk Youth, Elderly Home Health Care or Assisted Living Facilities?*

Yes

If you are providing services for 'not-developmentally disabled' individuals you do not qualify got this program.

3. Are all developmentally disabled individuals in your home 18 years of age or older?*

Yes

All clients living in your home MUST be over 18 years of age. Please contact our office at 303-333-0375 for details. Due to the nature of this answer, this application cannot be processed online.

4. Do any of your clients have a criminal history of physical abuse or are they on the sex offender registry?*

Yes

Please contact our office at 303-333-0375 for details. Due to the nature of this answer, this application cannot be processed online.

5. Are you providing any foster care or child day care services for anyone that is under the age of 18?*

Yes

All clients living in your home must be over 18 years of age. You are ineligible for this insurance program if you are providing foster care for children under the age of 18. Please contact our office at 303-333-0375 for details. Due to the nature of this answer, this application cannot be processed online.

6. Has your placement agency inspected your Host Home and do they make periodic visits throughout the year? (This is a requirement)*

Yes

This is a STATE REQUIREMENT for all Host Home Providers. If routine visits are not being conducted you cannot proceed with this application. You can contact our agency for further information at 303-333-0375.

7. Have you authorized your agency to initiate a background check on you and anyone 18 years of age or older living in your home? (This is a requirement)*

Yes

This is a STATE REQUIREMENT to be a Host Home Provider. Please notify your agency. You MAY NOT proceed with the application process.

8. Do you have homeowners or renters' insurance on your current residence?*

Yes

You must either have Homeowners Insurance or Renters Insurance in order to obtain Host Home Provider Insurance. If you DO NOT have either Homeowners or Renters Insurance, please call 303-333-0375.

9. How many years of experience do you have as a Host Home Provider?*

10. Do you provide any LICENSED SKILLED NURSING CARE to your clients other than issuing medication and basic care?*

Yes

We are unable to insure Host Home providers who do "skilled medical care" to their clients. Please contact our office at 303-333-0375 for details. Due to the nature of this answer, this application cannot be processed online.

11. Within the last 5 years, have you been subject to any form of disciplinary action as a Host Home Provider by a Court, a Community Centered Board, a Service Provider organization or any other placement agency you are contracted with?*

Yes

Please contact our office at 303-333-0375 for details. Due to the nature of this answer, this application cannot be processed online.

12. Have you ever had an allegation of Mistreatment, Abuse, Neglect or Exploitation?*

Yes

12a. Was this allegation substantiated?*

Yes

Please contact our office at 303-333-0375 for details. Due to the nature of this answer, this application cannot be processed online.

13. Have you had a lawsuit filed against you as a Host Home Provider?*

Yes

Please contact our office at 303-333-0375 for details. Due to the nature of this answer, this application cannot be processed online.

14. Are you aware of any incident in the past which could result in a lawsuit being filed against you?*

Yes

Please contact our office for further clarification at 303-333-0375.

15. Has any insurance company cancelled or non-renewed similar coverage?*

Yes

This would be Professional Liability Insurance and if it was cancelled or non renewed please our office at 303-333-0375.

16. Minimum required training. Check all that apply.

First Aid

CPR

Abuse Neglect Training

Other

How many clients are in your home between the ages of 18-64?*

How many clients are in your home 65 years of age or older?*

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Total Client Count

INFORMATION FOR INDIVIDUALS SERVING ANYONE OVER THE AGE OF 65

* IF YOU HAVE ANY CONSUMERS 65 +, THE NEXT SIX QUESTIONS MUST BE ANSWERED.

1. Is your consumer ambulatory? [Can they walk on their own without assistance?]

Yes

2. Is your consumer in a wheelchair all or most of the time?

Yes

3. Is your consumer confined to a bed?

Yes

4. Does your consumer require medical or skilled nursing care in your home?*

Yes

Due to the nature of this answer, this application cannot be processed online. Please contact our office at 303-333-0375 for details.

5. What kind of support does our consumer need assistance with? Check all that apply:

Cook

Bathe

Clean

Administer Medications

Other

IMPORTANT DISCLOSURES ABOUT YOUR INSURANCE COVERAGE

THE APPLICANT DECLARES THE ABOVE STATEMENTS AND REPRESENTATIONS ARE TRUE AND CORRECT AND THAT NO FACTS HAVE BEEN SUPPRESSED OR MISSTATED. THE COMPLETION OF THIS APPLICATION DOES NOT BIND THE COMPANY TO SELL NOR THE APPLICANT TO PURCHASE THIS INSURANCE, BUT ANY SUBSEQUENT CONTRACT ISSUED WILL BE IN FULL RELIANCE UPON THE STATEMENTS AND REPEPRESENTATIONS MADE IN THIS APPLICATION AND THIS APPLICATION WILL BE MADE A PART OF THE POLICY.

THE APPLICANT UNDERSTANDS THAT ANY COVERAGE PROVIDED BY THE COMPANY WILL BE PART OF A MASTER INSURANCE PROGRAM WITH A $1,000,000 LIMIT OF LIABILITY PER CLAIM AND A MAXIUMUM POLICY AGGREGATE LIMIT OF $5,000,000 (THEREFORE, IT IS POSSIBLE THAT CLAIMS ASSOCIATED WITH OTHER HOST HOMES MAY PARTIALLY REDUCE OR ENTIRELY ELIMINATE LIMITS OF LIABILITY AVAILABLE TO YOU.

THE POLICY UNDER THIS PROGRAM IS A CLAIMS-MADE POLICY WHICH PROVIDES LIABILITY COVERAGE ONLY IF A CLAIM IS MADE DURING THE POLICY PERIOD OR ANY APPLICABLE EXTENDED REPORTING PERIOD.

THE CONTRACT UNDER THIS PROGRAM IS DELIVERED AS A SURPLUS LINES COVERAGE UNDER THE "NONADMITTED INSURANCE ACT". THE INSURER ISSUING THE CONTRACT IS NOT LICENSED IN COLORADO BUT IS AN ELIGIBLE NON-ADMITTED INSURER. THERE IS NO PROTECTION UNDER THE PROVISION OF THE COLORADO INSURANCE GUARANTY ASSOCIATION ACT.

NO CANCELLATION REFUNDS WILL BE ISSUED EVEN IF CONTRACTS CHANGE MID-YEAR. ALL APPLICANTS MUST BE APPROVED PRIOR TO BINDING COVERAGE. CERTIFICATES OF INSURANCE WILL BE ISSUED UPON APPROVAL.

PLEASE ENTER YOUR FULL NAME:*

This program is for Host Homes serving 1 - 3 clients. Please verify the client count at the top of this page.

**SHOULD YOU RECEIVE AN ERROR MESSAGE AFTER SUBMISSION DUE TO AN ADDRESS OR (AVS) MISMATCH DO NOT continue to resubmit the transaction. Continued resubmission may result in premiums being withdrawn from your bank account multiple times. Contact or office for further assistance. 303-333-0375

Host Home Rate Taxes and Fees

Price:

Credit Card Processing Fee (2%)

$0.00

Total

Billing Address of the Credit Card*

Street Address Address Line 2 (Optional) City State ZIP Code

Cardholder Email

If you have no email address, you will not receive an email confirmation of payment.

Cardholder Phone*

Credit Card*

Discover

MasterCard

Visa

Supported Credit Cards: Discover, MasterCard, Visa

Card Number

Expiration Date Month Year

Security Code Name of the Credit Card Holder

**SHOULD YOU RECEIVE AN ERROR MESSAGE AFTER SUBMISSION DUE TO AN ADDRESS OR (AVS) MISMATCH DO NOT continue to resubmit the transaction.

Continued resubmission may result in premiums being withdrawn from your bank account multiple times. Contact our office for further assistance. 303-333-0375