ASSISTED LIVING LIABILITY INSURANCE & BONDING
Download A Paper Application
Need Assistance? Call Jason Miller at
800-866-2682, Ext. 101 or direct 210-618-0314
SECTION I - APPLICANT INFORMATION
Full Corporate Name:
Name On License:
Number of Beds:
Years in business under this name:
Number of staff working 7:00 AM to 9:00 PM
Number of staff working 9:00 PM to 7:00 AM
Do you perform criminal background checks on all employees?
Is smoking allowed on premises?
If YES, is it in a supervised and specific area only
Is there a swimming pool or hot tub on the premises?
If YES, is the pool area completely and separately fenced and secured?
SECTION III - GENERAL UNDERWRITING INFORMATION
Desired Effective Date:
Are you currently insured for General & Professional Liability?
If yes, please complete the following items, or fax your current declarations pages to Jason Miller at 866-847-7232: 1) Name of Insurance Company 2) Coverage Form: 3) Retroactive Date: 4) Limits of Insurance: 5) Current Premium: