Sponsored Insurance Program

ERRORS AND OMISSIONS LIABILITY APPLICATION

APPLICANTS INSTRUCTIONS:
1. Answer all questions. If the answer requires detail, please attach a separate sheet.
2. Application must be signed and dated by owner, partner or officer.
3. Note: Membership in DATIA is required for consideration in this program.
4. Signing of this application does not bind the Company to offer or the Applicant to accept insurance.
5. It is agreed that this application will be part of the insurance policy, if issued. This is an application form for a claims made policy.
I. GENERAL INFORMATION:
Company Name:
Company Address:
Contact Name:
Phone Number:
Fax Number:
E-mail Address:
Name of Executive Officer in Daily Management:
Title of Executive Officer in Daily Management:
Type of Business: Sole Proprietorship Corporation Partnership
Year Your Business Began:

II. LOSS HISTORY:
A. Has there ever been a claim against you in the past? Yes No
If "yes" then please furnish loss history (3 years) for all claims alleging errors in the drug testing process.

Date Claim
First Made

PaidDamages/Expenses
Including Attorney Fees

Outstanding Damages/Expenses
Including Attorney Fees

Total Damages 

**Please provide a full description of each claim on a separate sheet.

B. Are you aware of any facts, incidents or circumstances which may result in claims being made against you currently under the proposed insurance policy?

 Yes No
(If yes, please provide details on separate sheet)

C. Has the proposed coverage ever been purchased before, whether specifically or as part of another insurance contract?

 Yes No

D. Has any insurer ever canceled or non-renewed this type of coverage?

 Yes No
(If yes, please provide details on separate sheet)

E. Have you or any of your employees ever been the subject of disciplinary or investigative proceedings or reprimanded by an administrative or governmental agency, hospital or professional association?

 Yes No
(If yes, please provide details on separate sheet)

F. Are you currently a member of the Drug & Alcohol Testing Industry Association (DATIA)?

Yes No

G. Do you currently have insurance?
Yes No

If "yes" then please provide the following information for any similar insurance, if any, carried during the last three years.

 Company

Policy
Limit

Deductible

Annual Premium

Policy
Term

III. EMPLOYEES: NUMBER Of EMPLOYEES
Full Time:
Part Time:

IV. SCOPE OF BUSINESS SERVICES:
Please answer the following and also attach your current service description brochures. If you answer "yes" to any of the following questions, please enter % of Clients' Total Tests in the second box. Do you perform any or all of the following services?(If you provide some, but not all of the services, please explain on an attached sheet.) As a Third Party Administrator/Facilitator:
(1) Obtaining, contracting with and managing collection sites, breath alcohol technicians, laboratories, medical review officers (MRO).


Yes


No
(2) Do you or your employees actually perform any of the above listed services.
Yes


No
If so, which: Collection Lab Tests Medical Review
(3) Urinalysis or alcohol blind specimen quality assurance.
Yes


No
(4) Preparation of or consulting on company policies on substance abuse.
Yes


No
(5) Random testing administration.
Yes


No
(6) 24-hr post accident and reasonable cause testing administration.
Yes

| No
(7) Other:

V. TEST ADMINISTRATION (including TPA, Collection and MRO):

Please provide estimated testing count for the coming year for the following classes. If your answer is "0" for the number of tests, please place a "0" in the box.

Number of Tests

A. Drug Test (Urine)

(1) Collection Only (by you/employee)

(2) Lab Test Only (by you/employee)

(3) Collection, Lab Test and Medical Review (by you/employee)

(4) Facilitation Only (TPA)

B. Alcohol Test (Breath or Blood)

(1) Performed by you/employee

(2) Performed by Independent Contractor

TOTAL NUMBER OF TESTS
Further explanation:

VI. MEDICAL REVIEW OFFICER (for each associated MRO):
Name:
Address:
Employee:
Independent:

Accrediting Organization:

VII. LABORATORY:

Please list all laboratories that provide testing services to any of your employer clients:

SAMHSA Certified
Yes No
Yes No
Yes No
Yes No

Any person who knowingly and with Intent to defraud any Insurance company or another person files an application for insurance containing any materially false information, or conceals for the purpose of misleading information concerning any fact material thereto, commits a fraudulent Insurance act, which is a crime and subjects the person to criminal and civil penalties.
Applicant's Authorized Signature (Principal, Partner or Officer Title)
Date:
This is a secure form but if you prefer to print this out our Fax is: (202) 315-3579

DATIA • 1325 G Street, NW, Suite 500#5001 Washington, DC 20005