2023-04-05_lfancy_2023 - 220465 - Renewal Updates Form - for review.docx

Renewal Information/Updates

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This signed and completed form and the information provided, form part of the terms and conditions of your policy

Description of Operations: Home Health Care Provider including

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 on this form or in your return email.

Please submit your updates to our office not less than 30 days PRIOR to your renewal

Staffing, 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

YOU DO HAVE THIS COVERAGE

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

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C. CERTIFICATES

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

D.  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 Winnipeg o/b Prairie Seniors at Home Inc. and Prairie Senior Care 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.

Policy  #: | 220465 | Renewal Date:  April 30th | Account #: | HOMECAR-17

Insured: | Home Care Assistance Winnipeg o/b Prairie Seniors at Home Inc. and Prairie Senior Care Inc. | Telephone: | 204-489-6000

Mailing Address:
Risk Location: | #340 – 530 Kenaston Boulevard, Winnipeg, MB, R3N 1Z4  
Same

Contact: | Lindsay Fancy | Email: | lfancy@homecareassistance.com

2022 Reported Updates | 2022 Reported Updates | This Year’s Updates | This Year’s Updates

# | Hours Worked | # | Hours Worked

RNs | 0 | 0

RPNs | 0 | 0

PSWs | 72,170.

Homemaker/Companion | 40 | 30,930.

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

Office/Admin.

Student Placements
please include field of study

Annual GROSS Revenue | $ 3,300,000. | $      .

Annual Payroll | $ 1,900,000. | $      .

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

Certificate Holder | Required | Not Required

Proof of Insurance – Generic, To Whom it May Concern

HCA Home Care Assistance Canada Inc.

Kenaston Grant Holdings Ltd. – landlords

Coverage | Limits | Comments

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

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 | $   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 | $         21,228. | Desks, chairs, cabinets, equipment – 1861 Marine Dr.

Leasehold Improvements 
If applicable, please provide a value to insure | $            . | Interior walls, plumbing, wiring, HVAC, flooring etc.
Unsure of the value of your Leasehold Improvements ?                                                                Please advise the square footage of your unit      
An office in your home does not require this coverage

Stock | $             . | Any goods/items that you sell to clients, uniforms, PPE etc.

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)