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2022-04-26_scygan_Toronto 2022 FORM - 210329 - Renewal Updates Form - Toronto.docx
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Renewal Information/Updates
Page 1 of 3
Toronto Staffing details and revenues
Location: 70 Richmond Street East, Toronto, ON M5C 1N8
Contact: Timothy Thomas
Homecare Assistance Toronto o/b SJD Care Services Inc.
Income and Payroll - Please show annual figures, not monthly figures.
Numbers and Hours on the left side come from the form you submitted last year or from your application form.
If you have knowledge of a new contract (or expiry of an existing contract) which would affect your upcoming staffing levels, please add a note to your return email providing the details when you submit this year’s form.
(include the revised staffing details - RNs/RPNs/PSWs/Homemakers and projected hours).
Facility Staffing - Please advise the percentage of your annual revenues derived from Facility Staffing
Facility staffing is now specifically excluded from the Home Healthcare Program policy. If you are providing staff to any facility (long term care home/retirement home/hospital/etc.), your policy can be endorsed to provide the required coverage
The exclusion applies to any service contract you have that is written in the facility name
This exclusion does not apply if you are contracted by an individual whose home is a care facility
*NOTE: Your current policy will not provide coverage for staff provided to Correctional Institutions. This type of operation requires a specialized insurance product. If you are providing staff to any type of Correctional Institute please notify us immediately
Page 2 of 3
MAVENCARE Staffing details and revenues
Location: 70 Richmond Street East, Toronto, ON M5C 1N8
Contact: Timothy Tomas
Income and Payroll - Please show annual figures, not monthly figures.
Numbers and Hours on the left side come from the form you submitted last year or from your application form.
If you have knowledge of a new contract (or expiry of an existing contract) which would affect your upcoming staffing levels, please add a note to your return email providing the details when you submit this year’s form.
(include the revised staffing details - RNs/RPNs/PSWs/Homemakers and projected hours).
Facility Staffing - Please advise the percentage of your annual revenues derived from Facility Staffing
Facility staffing is now specifically excluded from the Home Healthcare Program policy. If you are providing staff to any facility (long term care home/retirement home/hospital/etc.), your policy can be endorsed to provide the required coverage
The exclusion applies to any service contract you have that is written in the facility name
This exclusion does not apply if you are contracted by an individual whose home is a care facility
*NOTE: Your current policy will not provide coverage for staff provided to Correctional Institutions. This type of operation requires a specialized insurance product. If you are providing staff to any type of Correctional Institute please notify us immediately
Page 3 of 3
Current Coverage/Limits
*It is your responsibility as the policyholder to select the values to insure on your policy. You must NOT construe any insured limit shown, as a representation from us, that it will be sufficient coverage.
PLEASE confirm the following
I/We are not aware of any circumstances, complaints, claims, potential claims, losses, penalties or fines levied against Home Care Assistance Toronto, Mavencare Inc. and/or HCA Home Care Assistance Canada Inc., in relation to the risks for which we are insured.
No claims OR describe any/possible/potential claims (if any):
Signature: ___
Print Name ___
Title/Position ___
Premium Payment: Payment in full is due on the effective date of coverage
We accept cheque, credit card and e-transfer methods of payment
Monthly Payments and two/three payment options are available through First Insurance Funding, please contact us for the enrollment forms.
Account Executive: Frank Stigter, fstigter@brokerlink.ca │647-299-2766
Account Manager: Fabie Carcone, fcarcone@broklerlink.ca │905-727-4605 or 1-800-268-3394, Extension 85691
Account Manager: Wendy Oliver, woliver@broklerlink.ca | 905-727-4605 or 1-800-268-3394, Extension 41308
Business Property | Value Insured | A signed Statement of Values form is required
Office Contents | $ . | Desks, chairs, cabinets, equipment
Leasehold Improvements | $ . | Interior walls, plumbing, wiring, HVAC, flooring etc.
Stock | $ .
2021 Reported Updates | 2021 Reported Updates | This Year’s Updates | This Year’s Updates
# | Hours Worked | # | Hours Worked
RNs | 0
RPNs | 0
PSWs | 100 | 100,000
Homemaker/Companion | 0
Others ? Footcare, Physiotherapists, Occupational Therapists, etc? | #
Describe:
Office/Admin. | 4 | 8000
Student Placements
please include field of study
Annual GROSS Revenue | $ 2,500,000. | $ .
Annual Payroll | $ 1,400,000. | $ .
Percentage of annual revenues derived from Facility Staffing
OR provide your annual revenue from Facility Staffing | % OR $
RESPONSE REQUIRED
Business Property | Value Insured | A signed Statement of Values form is required
Office Contents | $ 30,000. | Desks, chairs, cabinets, equipment
Leasehold Improvements | $ . | Interior walls, plumbing, wiring, HVAC, flooring etc.
Stock | $ .
2021 Reported Updates | 2021 Reported Updates | This Year’s Updates | This Year’s Updates
# | Hours Worked | # | Hours Worked
RNs | 0
RPNs | 6 | 6113
PSWs | 67 | 67,647
Homemaker/Companion | 0
Others ? Footcare, Physiotherapists, Occupational Therapists, etc? | #
Describe:
Office/Admin. | 4 | 8000
Student Placements
please include field of study | 3 | 3930
Annual GROSS Revenue | new | $ .
Annual Payroll | new | $ .
Percentage of annual revenues derived from Facility Staffing
OR provide your annual revenue from Facility Staffing | % OR $
RESPONSE REQUIRED
Coverage | Limits | Comments
General Liability | $ 5,000,000. | $25,000,000 Aggregate Limit
Abuse Liability | $ 1,000,000. | If you have made any changes to your Abuse Policy and/or Proceedures please send/attach an updated copy.
Professional Liability | $ 2,000,000. | Occurrence Basis or Claims Made Basis
Crime | $ 200,000.
$ 200,000. | - Employee Dishonesty
- Third Party Employee Dishonesty
Facility Staffing Liability | $ 5,000,000.
Legal Expense | Included
Business Property | A signed Statement of Values form is required
Property of Every Description | $ 415,320.
Business Property Limits
Under the terms of your policy it is required that you insure your Business Property and Leasehold Improvement to 100% of the replacement cost so, for better accuracy we are requesting a breakdown of the value of your Property
Office contents –Furnishings (desks, chairs, cabinets), Equipment (copier, printer etc.), Stock (paper, promotional materials etc.)
Leasehold Improvements/Betterments - most leases make the tenant responsible for the physical structures/finishes within your
unit(s). This includes items such as interior walls, plumbing, wiring, HVAC, flooring etc.
- If you are responsible for the tenants improvements/betterments please provide a value to insure. If you are
unsure of the value please provide the square footage of your unit.
Stock – (if applicable) any goods/items/product that you sell to clients
A signed Statement of Values form is required (the form is included in this email)