2022-05-31_scygan_Canada - 2022 Waterloo and Oakville 2022 - 200180 - Renewal Updates Form.docx

Home Health Care Renewal Information/Updates

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Please submit your updates to our office no later than 30 days PRIOR to your renewal

If you have made changes to the services you provide or need changes to your coverage please include a brief description of your new operations/requirements in your return email.

Operations Description: Home Health Care Provider

A.  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.

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Employees, Income and Payroll

‘Last Year’ numbers come from the form you submitted for your previous renewal and/or application form.

Please show annual figures, not monthly figures.

The numbers you provide affect your coverage. Under-reporting could affect your Business Interruption and Professional Liability coverage so please be as accurate as possible.

For the staff numbers/hours, use the total amount for this past year. 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 providing the details when you submit this year’s form (include the staffing details - RNs/RPNs/PSWs/Homemakers and projected hours).

Facility Staffing - Please advise the percentage of your annual revenues derived from Facility Staffing

You do have this coverage.  Please provide the % of your Facility Staffing Revenues only in this section.

*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

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CERTIFICATES

The following holders of ‘Certificates of Insurance’ are on file, please confirm whether or not updated certificates are required.

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 Waterloo o/b Arya Healthy Living Inc. and Home Care Assistance, 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  ___

YES, please renew my First Insurance Funding – Monthly Payment Plan.

Note: if you have changed your banking information please provide a new VOID cheque

Please email your completed forms to Norinne, for assistance completing the forms please contact:

Frank Stigter - fstigter@brokerlink.ca │647-299-2766

Wendy Oliver - woliver@brokerlink.ca │905-727-4605 or 1-800-268-3394, Extension 41308

Policy  # | 200180 | Renewal Date:  June 10th | Account # | HOMECAR-07

Insured: | Home Care Assistance Waterloo o/b Arya Healthy Living Inc. and Home Care Assistance | Telephone: | 519-590-2792

Risk 1 Location:
Risk 2 Location:
Risk 3 Location: | #104- 375 University Avenue, E, Waterloo, ON   N2K 3M7  
#212 – 2525 Old Bronte Road, Oakville, ON  L6M 4J2
90 Burnhamthorpe Road West, 14th Floor, Mississauga, ON, L5B 3C3

Contact: | Madhu Vijayan
Angie Kunnath | Email: | madhu.vijayan@rogers.com
akunnath@homecareassistance.com

Coverage | Limits | Comments

General Liability | $   5,000,000. | Higher limits are available.

Abuse Liability | $   2,000,000. | If you have made any changes to your Abuse Policy and/or Proceedures  please send/attach an updated copy.

Professional Liability | $   5,000,000. | Occurrence Basis   or Claims Made Basis

Crime | $        50,000.
$        25,000. | - 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

Office Contents | $       20,605.
    $       21,545.
    $                0. | Desks, chairs, cabinets, equipment - Oakville
Desks, chairs, cabinets, equipment – Waterloo
Desk, chairs, cabinets, equipment - Mississauga

Leasehold Improvements 
If applicable, please provide a value to insure | $            .
    $            .
    $            . | Interior walls, plumbing, wiring, HVAC, flooring etc. - Oakville
Interior walls, plumbing, wiring, HVAC, flooring etc.- Waterloo
Interior walls, plumbing, wiring, HVAC, flooring etc. - Mississauga
*Unsure of the value of your Leasehold Improvements ?                                                                Please advise the square footage of your units

Stock | $             . | Any goods/items that you sell to clients

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
                                                                             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)

WATERLOO | As per Last Year’s Form 
               #                │  Hours Worked | As per Last Year’s Form 
               #                │  Hours Worked | This Year (as per most current financials)
               #                │  Hours Worked | This Year (as per most current financials)
               #                │  Hours Worked

RNs | 0

RPNs | 0

PSWs | 25 | 12,002

Homemaker/Companion | 65 | 55,615

Others ?   Footcare, Physiotherapists, Student Placements                 Describe:

Office/Admin

Annual GROSS Revenue | $ 2,167,070. | $      .

Annual Payroll | $ 1,354,794. | $      .

OAKVILLE | As per Last Year’s Form 
               #                │  Hours Worked | As per Last Year’s Form 
               #                │  Hours Worked | This Year (as per most current financials)
               #                │  Hours Worked | This Year (as per most current financials)
               #                │  Hours Worked

RNs | 0

RPNs | 0

PSWs | 6 | 3,000

Homemaker/Companion | 55 | 57,517

Others ?   Footcare, Physiotherapists, Student Placements                 Describe:

Office/Admin

Annual GROSS Revenue | $ 2,049,436. | $      .

Annual Payroll | $  1,291,361. | $      .

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

Certificate Holder | Required | Not Required

CWB Maximum Financial (1st Loss Payee)

CWB (2nd Loss Payee)

Peter Benninger (Waterloo landlord)

Proof of Insurance – Generic, To Whom it May Concern