Health Care Professional Bond

A small home health care business can attract many legal issues due to the nature of the service provided. Normally, when you apply for a license in your state to become the manager of a small home health care business, you will be required to submit a bond agreement before being able to commence operation.

Your bond is in place to protect your clients from any kind of malpractice within your business. Your bond should not only meet the state requirements, but exceed them to ensure that you are covered for all the possibilities that may arise whilst running your business.

It is important to remember that the nurses in your employ are human beings, and humans can make mistakes. As their employer, you are liable for anything that may go wrong as they attend to a patient in their home. Whilst a nurse is with a client in their home, they have limited access to equipment should an emergency arise. Although your employees are trained to handle emergencies, a great number of things can go wrong.

Your bond agreement is to protect your clients from any malpractice that may occur whilst they are in the care of your staff. Your clients will be able to quickly recover any financial losses that may have been incurred through purposefully illegal acts committed by your employees.

Before you sign your bond agreement and pay fees that are due, you should have to documentation checked by your local government to ensure that you are meeting all the state requirements that are necessary to become licensed.


Application for


Current or expiring quote we are looking to beat:


Name of previous surety company writing to the bond:


Section I: Bond Applied for

Type of Bond

Effective Date

Expiration Date


Type of Company

CORP

LLC

DBA

Partnership

Bond Amount


(Obligee)


Obligee Address


Section II: General Information

Applicant's Name

Spouse Name


SS#

Spouse SS#

Home Phone


Residence Address

City

State

Zip


Status of Residency

Own

Rent

At Current Address Since


Date of Birth

Spouse Date of Birth

Business License Number


Business Name


Business Phone

Business Fax

Business Email


Business Address

City

State

Zip


Date Business BEGAN Under Present Individual or Firm Name

Business Tax ID


Has any company refused to issue bonds for any purpose?

Yes

No

Do you have any liens, claims or judgements against you?

Yes

No


Has applicant ever failed in business?

Yes

No

Has applicant filed bankruptcy in the last 10 years?

Yes

No


If yes, Chapter 7?

Yes

No

Chapter 11?

Yes

No

Chapter 13?

Yes

No


Date Filed for Bankruptcy?


Date of Discharge?


If yes to any, please explain:


Section III: Additional Parties

Name

Spouse Name


SS#

Spouse SS#

Home Phone


Home Address

City

State

Zip


Personal Financials

(if more than one owner, each has to fill out this app)

Statement of assets and liabilities as of


Assets Liabilities
Cash in Bank Notes Payable to Banks
Cash on Hand Notes to Others(excl. of equipment)
Stocks and Bonds Accounts Payable
Accounts Receivable Federal and State Income Tax Due
Notes Receivable All Other Taxes
Inventory Accruals, Payrolls, Etc.
Cash Value Life Insurance    
Equipment Due on Equipment
Real Estate Due on Real Estate
Other Assets Other Liabilities
    Surplus and Undivided Profits
    Capital Stock(if a corporation)
       
Total Assets Total Liabilities

Net Worth


Name of Owners

Name and Title of Officers

% of Ownership


Are you an insurance agent?

Yes

No

Agent License #

Agent State

Completion of this form constitutes permission for Cal Society Insurance Services to obtain customer information which will be used to determine bonding eligibility. This information will be held in the strictest confidence.