Synergy Coverage Solutions, LLC 217 S. Tryon Street Charlotte, NC 28202 www.synergyinsurance.net

T 704.927.2860 F 704.927.2867 info@synergyinsurance.net

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: _________________