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Nature of Corporate Structure:
Limit of Liability:
Address line 1:
Address Line 2:
Location Adress Line 1:
Location Address Line 2:
Location Zip Code:
Admin Phone Number:
# of Licensed Beds:
# of Occupied Beds:
# of Independent Living Apartment Units:
Are the Independent Living Apartment Units on the same or adjacent property to the assisted living facility or group home facility?
Any adjacent separate Administration office buildings?
# of Buildings:
Any adjacent separate Property Management buildings?
# of Buildings:
Any adjacent warehouse or maintenance buildings?
# of Buildings:
# of Full Time Employees:
# of Part Time Employees:
Legal Name of Organization:
Describe Business Operation:
Date Business Operation Started:
Number of years this business has been under the same ownership/administration?
Total number of years working experience in ownership, management or operations of an Assisted Living and/or Group Home facility?
Proposed Effective Date for Coverage:
Name of Expiring/Previous Insurance Carrier:
Any loss incidents or reported claims in the past 5 years?
Has the Expiring or Previous Coverage been cancelled; declined or non-renewed in the past Three (3) years?
3. Does the Facility care for the following residents?
Alcohol or chemically dependent residents
Insulin dependent diabetic residents
Renal dialysis residents
Are there residents that require immediate nursing care?
Are there residents that require skilled nursing care?
Does the Facility require all new resident health to provide a current resident health assesment form dated within thirty (30) days from their attending Physician to certify that the resident is qualified for admission to an Assisted Living or Group Home facility?
Does the Facility care for Mental Illness/Disorder residents?
In relation to those Residents that have maladaptive (aggressive) behaviors, on a scale of 1 to 10 (10 being the most aggressive), where do the worst cases fall (e.g. 1, 2, 8, etc.)?
Are they a threat to the safety of themselves and others?
Does the Facility care for troubled (substance abuse)/aggressive/maladaptive behavior teens?
Does the facility provide care for delinquent youth and other groups with criminal histories?
8. Does the facility have the following written policies/plans/programs?
Written emergency evacuation plan?
Missing resident policy?
Formal written safety program?
Does the Facility have a history of residents eloping or becoming 'missing' from the facility?
Are residents held with restraint devices on a regular basis?
Has the facility ever had any sexual misconduct incidents?
Do residents need 24 hour constant medical care from a professional medical or nursing staff due to the severity of their condition?
13. Does the Facility have the following monitoring systems?
Wander Guard/ Care Track system?
Alarms on external doors?
Connected to a central station (ADT, Ackerman, etc.)?
Is the building facility sprinklered?
Are the smoke and fire detectors connected to the monitoring systems?
Has the Facility ever had an unexplained or unsatisfactorily explained death or injury?
In respect of the staff that are required to be licensed and registered, has their credentals been verified and kept up to date?
At least one (1) licensed caregiver (CPN, LPN, Med. Tech) available 24 hours/7 days per week?
Based on nursing staff requirements, what is the average working hours per week per facility of residents?
Is this facility a mixed population of young and elderly residents?
Are fire, elopement, and disaster drills conducted regularly?
What's the Date of the last fire drill?
What's the Date of the last development drill?
What's the Date of the last disaster drill?
Pond, lake, or pool on premises?
Is it fenced?
Fence height (ft)?
Gate locked when not in use?
Use of pool supervised?
Is transportation for residents provided?
Are all the drivers licenses checked to ensure that good driving records exist?
Are there any other Independent Contractors?
Do they have appropriate liability and/or Workers Compensation Insurance?
How often are safety meetings held?
Is there at least one currently certified person trainedin CPR and First Aid on duty?
Does the applicant ever admit residents to its facility(ies), or allow residents to remain in its facility(ies), when such residents require a higher level of care than the applicant is permitted by state and/or federal licensing authorities to provide?
At least one licensed Caregiver ( CNA, LPN, Med. Tech ) 24/7?
Same owner/admin for at least three years?
Add any attachments related to this application below: BY SIGNING BELOW, YOU ARE ACKNOWLEDGING THAT (I) YOU HAVE ANSWERED THE QUESTIONS IN THE APPLICATION TO THE BEST OF YOUR ABILITY AND DECLARE, THAT, TO THE BEST OF YOUR KNOWLEDGE, THE STATEMENTS SET FORTH THEREIN ARE TRUE AND CORRECT, AND YOU ARE FURTHER DECLARING THAT THE FACILITY(IES) TO WHICH THIS APPLICATION RELATES IS NOT PROVIDING AND WILL NOT IN THE FUTURE PROVIDE SERVICES TO RESIDENTS BEYOND THOSE WHICH IT IS SPECIFICALLY LICENSED TO PROVIDE BY THE STATE OR FEDERAL LICENSING AUTHORITIES. (II) SIGNING THE APPLICATION AND RECORDING YOUR NAME TO THIS APPLICATION DOES NOT BIND THE INSURANCE COMPANY TO COMPLETE THE INSURANCE, BUT IT IS AGREED THAT THIS APPLICATION SHALL BE THE BASIS OF THE CONTRACT SHOULD A POLICY BE ISSUED. (III) YOU FURTHER UNDERSTAND THAT ANY INCORRECT OR INCOMPLETE STATEMENT IN THE APPLICATION COULD VOID PROTECTION SHOULD A POLICY BE ISSUED. ANY PERSON KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRADULENT INSURANCE ACT, WHICH IS A CRIME AND SUBJECT SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES. I FURTHER UNDERSTAND THAT THE PROFESSIONAL AND GENERAL LIABILITY COVERAGE LIMITS ARE CHOSEN AND REFERENCED ABOVE FOR THE PER CLAIM AND AGGREGATE AMOUNTS (WITH A MAXIMUM OF $1,000,000 FOR PROVIDERS WITH MULTIPLE LOCATIONS) AND THAT ANYTHING ABOVE THIS AMOUNT IS MY RESPONSIBILITY.