Professional and General Liability Insurance Application for: All licensed Social Services Business Section 1 of 2 "*" indicates required fields Step 1 of 2 50% FacebookThis field is for validation purposes and should be left unchanged.First Named Insured*DBAMailing Address Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Cell phone numberEmail Address* Facility license numberFEINEffective date MM slash DD slash YYYY Retro date MM slash DD slash YYYY Prior Carrier NamePrior Premium $*Prior limits of insurance / (per occurrence and aggregate limits)Regarding any/all locations - check all that apply or check here if none Bankruptcy (current/future) Admit known Felons Hospice Services (non-contracted) In Receivership Provide Pediatric Services In Home Services (non-contracted) Hospital Affiliated Provide Child Care Services Stop Gap (OH, ND, WA or WY) Government Owned Special Focus Facility/ Candidate IN Patient Compensation Fund Psychiatric Facility REIT Real Estate Investment Trust Located in KS, MT, NM or WV Predominately non-elderly Under $25k Minimum Premium Is this account being non-renewed? Yes No Please provide detailsIs this account currently bare? Yes No Please provide detailsIs this account currently self insured? Yes No Please provide detailsHow many years of current ownership?Is there a management company Yes No Does the Management Co. work with any other facilities not included within this submission? Yes No Is there a HUD contract? Yes No Are the following performed when hiring a new employee that provides care and support staff (for all locations):Criminal background checks Yes No Please provide an explanationDrug testing Yes No Please provide an explanationLicensing/certification checks Yes No Please provide an explanationTrain on HIPAA privacy Yes No Please provide an explanationReference checks Yes No Please provide an explanationTrain how to recognize, investigate and report Abuse Yes No Please provide an explanationEducation Checks Yes No Please provide an explanationIs a criminal background check done on all Volunteers that have non-supervised contact with residents? Yes No Federal or State Findings last 24 months (for all locations) Complete as they apply or check here if None Of immediate jeopardy tags Of Civil Money Penalties Of Actual Harm Tags Of Denial of payment for Admissions Please read Carefully This application, including Section II Per location, and any attachment(s) in its entirety will be considered part of the policy. When the declaration and forms are distributed, a copy of the application you have provided will not be included. Please be sure to retain a copy of the application(s) for your file. An unsigned and undated application will not be considered. The signing of this application does not bind the company to offer insurance nor does it bind the signer. Printed NameSignatureTitleDate MM slash DD slash YYYY Continued Section 2:This application must be accompanied by Section II Per Location addendum Section II Per Location - The following must be completed for each facility location Loc NumberFacility LicenseFacility NameAddress Street Address City State / Province / Region ZIP / Postal Code Retro Date* MM slash DD slash YYYY Administrator: Yrs. at FacilityYrs. Exp.Medical Director: Yrs. at Facility Yrs. Exp. Apartment 55+ # of UnitsAny known incidents to be reported to expiring carrier:* Yes No If yes, please provide detailsPlease list the # of residents per age range 60+ qty 26 - 59 qty < 26 qty Number of residents*Please indicate additional GL exposure Storage Dwelling Office Vacant Bldg Parking Lot Vacant Land Parking Structure Acreage None to the above Any body of water? Pool Hot Tub/Spa Pond Other None to the above Any state of federal enforcement actions within the last 24 months? Yes No Please provide detailsIs this facility being considered for sale in the next 12 months? Yes No Please provide detailsDoes this facility have a specialized unit? Yes No Please provide detailsDoes this facility have a Locked Unit? Yes No Please provide detailsIs this facility used as a training site for student training programs? Yes No Please provide detailsDoes this Facility accept Residents who wander? Yes No Please provide detailsHas any of the facility license(s) been suspended or revoked within 5 years? Yes No Please provide detailsDoes this Facility have a Wander Guard System? Yes No Please provide detailsDoes the facility allow smoking? Yes No Is smoking staff supervised? Yes No Does Facility control ignition materials? Yes No Where is smoking permitted?List Owners that represent 5% or more ownership (provide on separate sheet as necessary)Are renovations kept up on Building, Electrical, Heating, Cooling, Plumbing and Roof? Yes No Is applicant aware of any recent circumstance which may result in any claim or suit being made (including requests for medical records) and not recorded on loss runs provided? Yes No Please provide detailsPrinted NameTitleSignatureDate MM slash DD slash YYYY Applications must be signed by an owner or principal of the LTC entity/or company and hereby represent that he/she has been authorized and has authority to sign legal documents on behalf of the Facility.Untitled* I acknowledge and agree to submit this information
