Individual Professional Liability Insurance Application

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Applicant

First name

Last name

Email address

Are you a Van Wagner policy holder

How did you hear about us

Please choose job position

Please choose profession classification

Description of services provided

List your professional licenses, degrees and certifications achieved

Years of experience/in business

Hours worked per week

Percentage of services provided for drug, alcohol and co-dependency counseling

Eligibility

Are you unlicensed in any state in which you are operating

Are you a full-time student

Are you being paid for professional services in the behavioral health field that you provide

Are you monitored and/or supervised by a licensed/certified counselor

Expected date of graduation

Are you a recovery coach or sober companion

Do you offer live-in services

Do you offer transport services

Do you provide any acupuncture services

Do you provide any equine services

Do you use hypnosis or hypnotherapy services

What % of your practice provides hypnotherapy

What services are offered via hypnotherapy

Do you sell any dietary supplements

Describe

Are you currently a CCAPP member

Are you currently a NANP member

Are you currently an ODAPCA member

Are you currently a NAADAC member

Are you a member of any other associations

Which association(s)

Do you provide services under a corporation that you are the owner/part owner

Aside from yourself, are there additional owners of the corporation

What is the corporation name

Do you have employees

Mailing Address

Street address (no PO Boxes please)

City

State

Zip code

Work phone

Home phone

Cell phone

Fax

Practice Address

Street address

City

State

Zip code

Coverage

Do you have a contractual obligation to include a state, municipal organization, similar agency, or landlord as an additional insured

First additional insured

Name

Street address

City

State

Zip code

Second additional insured

Name

Street address

City

State

Zip code

Practice Description

Indicate all locations where the Applicant(s) provide services (Total must equal 100%)

Location	% Time Spent
At Applicants' location
In Clients' homes
Prison/Jail/Detention
Other (calculated)

Other location description

Do you prescribe medication or administer methadone

Describe

Do you own or manage any residential facilities

Describe

Do you offer recreational activities in the treatment of patients

Describe

Do you provide counseling for sex offenders

Provide percentage of total services provided

How do you receive clients that have a history of sex offenses

Do you specialize in or advertise counseling to sex offenders

Have you ever testified or reported back to the court on your counseling sessions

Are patient records unprotected in opposition to HIPAA (Health Insurance Portability and Accountability Act of 1996)

Explain

Is an informed consent process in place

Are copies of informed consent forms maintained in patient files

License/Certification Information

Are you participating in any continuing education programs

Describe

Has your license or certification ever been revoked, suspended, refused, cancelled, or voluntarily surrendered

Describe

Date action taken

Have you been investigated by a state health department, state licensing board or other governmental body

Describe

Date of investigation

Have you been convicted of a felony or is any such charge pending

Describe

Date of conviction

Claims

Has a professional liability claim or suit been made against you

Describe

Has a general liability claim or suit been made against you

Describe

Has an abuse liability claim or suit been made against you

Describe

Have you ever had an incident that resulted in an allegation of sexual abuse

Explain

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Title

Individual Professional Liability Insurance Application

(Please login if you already have an account)

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First additional insured

Second additional insured

Indicate all locations where the Applicant(s) provide services (Total must equal 100%)