Inmate Medical Insurance - Hunt Insurance Group

Application

Name of Insured:

Name of Government Facility:

Contact Person:

Address:

City:

State:

Zip:

Telephone Number:

Fax Number:

Contact Email:

Average Inmate Daily Population:
(include those housed at other facilities and for whom you are responsible; exclude inmates you are housing for others and for whom you are not responsible)

Maximum Jail Capacity:

Average Length of Detention:

Please Indicate the Percentage of Inmates Detained...

Under 30 Days %

30 Days - 6 Months %

Over One Year %

Do you have an arrangement with a hospital to discount normal rates for service?

Yes

If Yes... How Much?

Do you have an on-site infirmary?

Yes No

Do you have case management staff to ensure proper monitoring of a hospital stay?

Yes No

Do you contract with a Correction Healthcare Provider?
If yes, who?

If Population Exceeds 200, Provide Total Inpatient/Inmate Medical Expenditures for the Past Three Years:

What hospital is primary caregiver?

Are they..

For Profit Non-Profit

Year

Total Inmate In-Hospital Expense

2005

2006

2007

Number of Claims Over $10,000 in the Past Three Years

Year

# of Claims

Total Expenses

2005

2006

2007

Are Any of These Claimants Currently Inmates in Your Facility?

	If So, Provide Their Prognosis?