Streamlining the Submission Process

• Professional & General Liability Insurance Application-Home Care, Hospice, Medical Staffing Firms
• COVID-19 Safety Procedures Supplemental Application Home Care Hospice Human Services
• MSP Workers’ Compensation Supplemental Application – Adult Day Care, Companion & Personal Care, Home Health Care, Visiting Nurse Associations (VNAs) & Medical Staffing Firms
• Human Services Organizations Application
  Including Residential Facilities, Outpatient Facilities, Substance Abuse Programs, Behavioral Health Programs, Adult Day Care, and Adoption/Foster Care.
• Miscellaneous Medical Professional Liability Applications
  Note – please complete this “main” application, along with the following supplemental application for misc. med. risks:
  • Ambulatory Surgery Centers
  • Blood Banks
  • Community Health Centers
  • Diagnostic Imaging Centers
  • Healthcare Clinics
  • Laboratory Facilities
  • Urgent Care Clinics
• Directors and Officers (D&O), Employment Practices (EPL) and/or Cyber Liability Application
• Breach Response Cyber ETrade Application (ed. 11/2018)
• Telemedicine Virtual Care Application
• Regulatory Audit Coverage – Supplemental Application

ACORD applications are acceptable for all other lines of business (i.e. property, crime, owned auto, etc.)

Submission Requirements

• Please include the following attachments with your submission:
  • Currently valued insurance company loss reports for the past three to five years
  • Most recent Experience Modification Worksheet (for Workers’ Compensation submissions)
  • Resumes of owner/operators (to verify management experience in health care), pro-forma financials and a business plan (if available) for firms that are new in business (less than two years)
  • Most current annual financial statement – audited or compiled (for D&O applicants)
  • Please note – Additional information may be requested by your underwriter once a submission is received and reviewed for eligibility
• Send your completed application(s) and all required attachments to:
  submissions@manchesterspecialty.com or fax to 1-603-647-9716.
• If you do not see a particular application or class code, contact us at info@manchesterspecialty.com.

If you have already completed an application for another program, we can often provide review of eligibility and a premium indication from a competitor’s application. We would just ask for our program application to be signed and completed when you choose to bind coverage with us.