ESBD_515780_1778790471889_Form 06-Provider Insurance Verification (VR 3445).pdf

VR3445 (03/20) Provider Insurance Verification Page 1 of 2

Texas Workforce Commission Vocational Rehabilitation Services

Provider Insurance Verification Instructions:

• For response to an Electronic State Business Daily (EBSD) posting, follow the instructions in the

ESBD posting, otherwise submit updated forms to the Quality Assurance Specialist for VR (Q) or Regional Program Support Specialist (RPSS) and Contract Manager.

• Follow instructions on the form and in the TWC VR Standards for Providers.

• Type all information on form using a computer and get all required signatures.

• Complete all sections of the form. Record “N/A” (not applicable) if a question does not apply.

• Keep a copy of your submitted form with attachments and supporting documentation for your records.

Reason for Submission Date of submission:

Application package Solicitation ID:

Update of information due to change in information on file. For example, qualifications change.

Other. Specify:

Entity’s Information Entity: The business that is requesting or has been granted the bilateral contract with TWC to provide services on behalf of VR customers.

Entity’s legal name:

Entity’s “doing business as” (DBA) name:

Provide at least one of the following:

Employer Identification Number (EIN) (9 digits, issued by IRS):

Last four digits of the sole proprietor’s Social Security Number:

Insurance Insurance requirement can be found in the VR Standards for Providers Chapter 3, section 3.2 Insurance Requirements. All contractors must carry the prescribed insurance.

Enter all insurance coverages below. The declaration of policy must be attached.

No insurance carried - Must complete next section’s certification statements.

Carrier’s name:

Type Amount and limitations Expiration Date

Declaration Attached

TWC- Verified Insurance

Yes No Yes No Yes No Yes No Yes No Yes No

VR3445 (03/20) Provider Insurance Verification Page 2 of 2

Carrier’s name:

Type Amount and limitations Expiration

Date Declaration

Attached TWC- Verified

Insurance Yes No Yes No Yes No Yes No Yes No Yes No

Insurance Certification Acknowledgment and Signature I, the legally authorized representative of the entity, certify the following:

The entity (contractor) has general or business liability insurance coverage that protects customers, employees, and visitors. Yes No

The entity provides services to VR customers in a location that is owned, leased, used in-kind, or otherwise controlled by the entity (contractor).

Yes No

• If yes, the entity (contractor) maintains premises liability insurance.

Note: Physical locations do not include community sites that are not owned, leased, or used as dedicated space by the contractor, such as state, federal, city, county, or other public meeting spaces.

Yes No N/A

The entity (contractor) and/or their staff transport customers in motorized vehicles.

Yes No

• If yes, contractors and/or their staff transporting customers meet the minimum liability requirements of the Texas Department of Insurance.

Yes No N/A

• If yes, contractors keep records, including proof of insurance and valid driver's license, for staff who have or may transport customers in vehicles. This information must be made available upon request.

Note: Contractors are not required to transport customers. When contractors and/or their staff transport customers they must meet the minimum liability requirements of the Texas Department of Insurance.

Yes No N/A

The entity acknowledges that it must keep on file with TWC a current and accurate declaration of policy or its equivalent for all insurance required by the TWC VR Standards for Providers and by the contract.

Yes No

Legally authorized representative’s printed name:

Title:

Legally authorized representative’s handwritten signature:

X

Date:

Agency Use Only Comments:

http://www.tdi.texas.gov/index.html