2022-04-26_scygan_Winnipeg 2022 FORM - 210329 - Winnipeg Renewal Updates Form.docx

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HCA HOme Care - Winnipeg Staffing details and revenues

Contact: Lindsay Fancy or

eMail: lfancy@homecareassistance.com or

Location 1: #10B - 1700 Corydon Avenue, Winnipeg, MB  R3N  0K1

Location 2: #140 – 600 St. Anne’s Road, Winnipeg, MB  R2M 3G7

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).

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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

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 Winnipeg o/b 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 | $       21,228. | Desks, chairs, cabinets, equipment

Leasehold Improvements | $            . | Interior walls, plumbing, wiring, HVAC, flooring etc.
If applicable, please provide a value to insure

Business Property | Value Insured | A signed Statement of Values form is required

Office Contents | $       20,000. | Desks, chairs, cabinets, equipment, includes Leasehold Improvements

Leasehold Improvements | $             . | Interior walls, plumbing, wiring, HVAC, flooring etc.
If applicable, please provide a value to insure

2021 Reported Updates | 2021 Reported Updates | This Year’s Updates | This Year’s Updates

# | Hours Worked | # | Hours Worked

RNs | 0

RPNs | 0

PSWs | 60 | 49,000

Homemaker/Companion | 40 | 27,400

Others ? Footcare, Physiotherapists, Occupational Therapists, etc? | #     
Describe:

Office/Admin.

Student Placements
please include field of study

Annual GROSS Revenue | $ 2,272,000. | $      .

Annual Payroll | $ 1,279,000. | $      .

Percentage of annual revenues derived from Facility Staffing
OR provide your annual revenue from Facility Staffing | %  OR  $         
 RESPONSE REQUIRED