EmailMe Form - THEFT/VALUABLES/DISCLOSURE/CYA

PROPERTY / VALUABLES DISCLOSURE

Hi! I wanted to write to you to touch base on an important item. As you know, Home Instead Senior Care is a licensed home care agency with over 15 years serving Manhattan’s elderly. We are fully insured against any theft resulting from any of our caregivers. All of our caregivers have impeccable backgrounds as per FBI fingerprinting and we have never needed to use this policy to date.

We recognize that our clients may have many valuables, including jewelry and other items, which can be lost or stolen. We also understand that there are numerous people who may come into the homes - our staff, housekeepers, physical therapists, handymen, housekeepers, Visiting Nurses, etc.

Effective immediately, our insurance company is requiring that we (and all other agencies they insure) ask each client to complete and submit this online form (where you are asked to itemize and declare any and all valuables). If you are not able to complete any portion of the form for any reason, or have any questions, please call Home Instead representative Balbina Polanco at (212) 614-8054 or email her at bal@homeinsteadny.com

Thank you!

Christian Steiner (owner)

E / P / L/ SS

Name of person filling this out *
Your Phone # *
Your Email *
Today's date *
MM / DD / YYYY
Name of senior where Home Instead personnel is working *
Your relationship to the senior *
Address where valuables are located *
(If you prefer to not itemize or make any descriptions, please indicate as such on the right)

Full Description of the items, including:

1. Name of item
2. Location of such item (if in safe, please mention safe)
3. Last time such item was actually seen by you

If there are certain items you prefer to not disclose for any reason, please make sure it is reported to your insurance company and please put it in a safe. *
Please attach pictures, Appraisal values, any other documentation for as many of the items listed in this form (optional)

Add File
Are all of these valuables present in the apartment today? *
Have these valuables been itemized and presented to your insurance company? (we recommend this) *
Have any documents with passwords, safe combinations been secured (we recommend this be done and removed from the apartment if possible) *
Would you feel more comfortable having a safe in the home for valuable items? (we recommend that you have one and that a trusted source not known to us have the combination). You can purchase great safes from Amazon.com *
Names of all people with access to the apartment, including:

- housekeepers
- handyman
- physical therapist
- friends
- neighbors *
BANKING/ CREDIT CARDS******
******
ATM/Debit or Cash Cards. Is somebody reviewing the checking account balances and activity on a monthly basis? (We highly recommend this be done at least on a monthly basis) *
ATM/Debit or Cash Cards. Home Instead senior care personnel are NOT allowed to ever touch an ATM/Debit or credit card or to know of the PIN or sign any financial transaction. If a client needs assistance in this area, they need to call our office but please do not ask a caregiver to ever assist in this. *
Check books. Is somebody reviewing the checking account balances and activity on a monthly basis? (We highly recommend this be done at least on a monthly basis) *
USE OF PIN CODES/ PASSWORDS/ SIGNING OF CHECKS. CREDIT CARDS ETC
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PIN CODES/ PASSWORDS. Home Instead caregivers are not allowed to know any pin codes or passwords for purposes of purchasing, signing for goods or getting cash. Please confirm this or let us know if there is an expectation that the caregiver have this information *
SIGNING CREDIT CARDS/ WRITING CHECKS. Home Instead caregivers are not allowed to sign credit cards, write or sign checks under any circumstances. Please confirm this or let us know if there is an expectation that the caregiver do this *
Please share any notes or concerns that you deem important, or might provide assistance in this matter:
Signature (please sign with your finger) *
Clear