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Synergy Coverage Solutions, LLC 217 S. Tryon Street Charlotte, NC 28202 www.synergyinsurance.net
T 704.927.2860 F 704.927.2867 [email protected]
Non-Emergency Medical Transportation Supplemental Application
Name: _________________________________________________________________________________
Website: _______________________________________________________________________________
1) What percentage of annual trips are emergency transportation? ______________%
2) Number of patient transport vehicles? _______________________________
3) Radius of operation: ____________________________________________________________________
4) Do you use independent contractors? Yes No
a) If yes, for what purpose? ___________________________________________________________
b) If yes, where is their WC coverage? __________________________________________________
5) Number of employees who drive on company business: _______________________
6) How frequently are MVRs checked for employees who drive on company business? (select all that apply)
Pre-hire More than once a year
Annually Less than once a year
7) What is the criteria for acceptable MVRs?
8) How often is defensive driving training conducted? ____________________________
9) How often are vehicles brought in for scheduled maintenance?
_____________________________________________________________________________________
10) Who maintains your vehicles? ____________________________________________________________
a) How many mechanics service your vehicles? ___________________________________________
b) Do you service other vehicles? Yes No
11) Do you have a Blood Borne Pathogen program? Yes No
12) What are your formal patient handling controls?
13) How often do you conduct patient handling training? __________________________________________
14) Do you have any employees that are part of a union? Yes No
Employer Signature: ____________________________________________ Date: _________________