Therapist Application

Therapists Program Pricing

MARCH 2024 -2025

Premiums:

$399.86 - Includes $11.65 in Surplus Lines Tax

How to File for a Trade Name

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%

Section 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):

Are you an LLC or S-Corp?*

Yes

Home Address*

Street Address City State ZIP Code

Home Phone Number*

Cell Phone Number:

Email Address:

List any additional office locations that you have. (If applicable)

Do you have EMPLOYEES or do you pay anyone to do services for you?*

Yes

This program is for INDIVIDUAL INDEPENDENT CONTRACTORS PROVIDERS only. Coverage does not extend to employees or contracted Therapists. Please contact our office for further clarifications at 303-333-0375.

Your Professional Service (Check all that apply)

Behavior Therapist

Special Education

Occupational Therapist

Cognitive Therapist

Speech Therapist

Early Intervention

Rehabilitation Counselor

Music or Art Therapist

Other Professional Services

Are you currently contracted with, or planning to be contracted with a state placement agency, Community Centered Board or other State Funded organization?*

Yes

Name of Agency/Organizations:*

You must have a contract with, or plan to have a contract with a State Funded organization in order to purchase insurance.

Section 2: Underwriting Questions

General Information Questions

1. Are the consumers that you provide services for developmentally disabled?*

Yes

2. Are you currently licensed or certified and in good standing in the state for the Professions listed above? (If certifications are required)*

Yes

3. Have you ever been refused coverage for professional liability or malpractice or has your malpractice liability insurance ever been cancelled or declined for renewal?*

Yes

If yes please explain.

Describe the reason for cancellation or non renewal:*

4. Has any claim or lawsuit been filed against you for alleged malpractice or professional liability, or are you aware of any incident or existing circumstances that might reasonably lead to a claim or suit?*

Yes

If yes please explain.

Describe the claim or situation:*

5. Have you ever had your license, certification or registration suspended, revoked or placed on probation by a licensing board of examiners or any other governmental entity that regulates your profession?*

Yes

Please give a brief description:

Please give a brief description:*

6. Have you ever surrendered either voluntarily or otherwise, your license, certificate of registration, if one is required?*

Yes

Please give a brief description:

If yes please give a brief description of why you surrendered your certification:*

7. Have you ever been accused of sexual misconduct or any professional impropriety?*

Yes

Please give a brief description:

If yes please give a brief description the accusation:*

8. Have any complaints ever been filed against you with a peer review committe or an ethics committee of a professional association, hospital, health care facility, licensing board, or any other governmental or private entity?*

Yes

Please give a brief description.

If yes please give a brief description of the complaint:*

9. Do you know of any reason why you cannot comply with the legal, ethical, or professional standards set by law, by regulation, by a peer review committee or by any applicable code of ethics in any jurisdiction where you provide services?*

Yes

Please give a brief description:

If yes please give a brief description:*

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.

PLEASE ENTER YOUR FULL NAME:*

Annual Premium*

Price:

Credit Card Processing Fee (2%)

Price: $0.00

Total

Billing Address of Credit Card*

Street Address Address Line 2 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