Respite, In-Home Support and Community Access Program Pricing MARCH 2026 - 2027 Premiums: $452.18 - Includes $13.15 in Surplus Lines Tax and $0.77 in Surplus Lines Processing Fees Please complete all of the information in the Online Application. Should you have any questions feel free to contact us. "*" indicates required fields Step 1 of 3 33% This field is hidden when viewing the formApplication Year2026-2027Section 1: General Information Are you new to the Care Association?* I am Renewing I am New I am not sure Full Name:*Trade Name (If applicable):Home Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Phone Number*Cell Phone Number:Email Address: Are you a Family Care Giver?* Yes No Do you have EMPLOYEES, or do you pay anyone to perform the services for which you as a Respite Worker are to perform?* Yes No This program is for INDIVIDUAL INDEPENDENT CONTRACTORS PROVIDERS only. If you pay someone to work for you, you must contact our office for further clarifications at 303-333-0375.Are you providing services for 'non-developmentally' disabled individuals, i.e. At Risk Youth, Elder Home Health Care or Assisted Living Facilities?* Yes No If you are providing services for 'non-developmentally disabled' individuals you do not qualify for this program.List all Agencies that you are contracted with for the services you provide:* Section 2: Underwriting Questions General Information Questions 1. Are the consumers that you provide services for developmentally disabled?* Yes No All of you consumers must be developmentally disabled. Due to the nature of this answer, this application cannot be processed online.Check the age groups that you provide services for: Under 18 years old Between 18 and 65 65 years old and over 2. Do you provide overnight respite services to the individuals you serve?* Yes No 2a. Do you provide overnight respite in your clients home?* Yes No 2b. Do you provide overnight respite to your clients in your home?* Yes No If you provide overnight respite in your home do you have renters or homeowners insurance?* Yes No Homeowners or Renters insurance is required in order for you to provide respite services in your home.3. Do you provide in-home support services to the individuals you serve?* Yes No 4. Do you provide any LICENSED SKILLED NURSING CARE to the individuals you provide services for, other than issuing medication and basic care? Yes No If you provide SKILLED MEDICAL CARE you do not qualify for this program. You may contact our office for further clarification.5. Do you take the individuals that you provide services for out into the community i.e. the park, shopping, movies, etc?* Yes No 6. Have you authorized the organization or placement agency to initiate a background check on you and anyone 18yrs of age or older living in your home (This is a requirement)?* Yes No This is a STATE REQUIREMENT. Please notify your agency. criminal background checks on providers are required. You MAY NOT proceed with the application.7. Within the last 5 years, have you been subject to any form of disciplinary action as a service provider by an agency that you are contracted with to provide services?* Yes No Please give a brief description of the incident.Please give a brief description of the disciplinary action that was brought against you:*8. Have you ever had an allegation of Mistreatment, Abuse, Neglect or Exploitation?* Yes No Please give a brief description of the incident.Please give a brief description of the allegation that was brought against you?*This field is hidden when viewing the form8b. Was this allegation substantiated?* Yes No Please give a brief description of the outcome.If yes please give a brief description of the outcome:*9. Have you had a lawsuit filed against you as a Respite Care provider?* Yes No Please give a brief description of the lawsuit.If yes please give a brief description of the lawsuit:*10. Are you aware of any incident in the past which could result in a lawsuit being filed against you?* Yes No Please give a brief description.If yes please give a brief description:*11. Has any insurance company cancelled or non-renewed similar coverage?* Yes No Please give a brief description of the cancellation and the reason given.If yes please give a brief description:*12. Please check all training you have received to qualify you as a provider? First Aid CPR Abuse Neglect Training Other 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:* **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. 303-333-0375Respite Care Insurance* Price: Credit Card Processing Fee (2%) $0.00 Total Billing Address of the Credit Card* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Cardholder Email If you have no email address, you will not receive an email confirmation of payment.Cardholder Phone*Credit Card* DiscoverMasterCardVisaSupported Credit Cards: Discover, MasterCard, Visa Card Number Expiration Date Month Month010203040506070809101112 Year Year20262027202820292030203120322033203420352036203720382039204020412042204320442045 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
