ASSISTED LIVING LIABILITY INSURANCE & BONDING
Download A Paper Application
Need Assistance? Call Jason Miller at
800-866-2682, Ext. 101
SECTION I - APPLICANT INFORMATION
Full Corporate Name:
Street Address:
Federal Employer Identification Number (FEIN):
Contact Name:
Type of Business (Check All That Apply)
Do you rent, sell or service any products:
If yes, please indicate total revenue attributable to products:
Do you perform criminal background checks on all employees?
Years in business under this name?
Gross revenue for the past 12 months:
Gross revenue estimated for the next 12 months:
Do you provide any of the following services?
Number of Beds By Type: Licensed Occupied Number of Residents by Class: Occupied
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:
Do you have a fall assessment protocol?
Is video surveillance used?
Please state the name of the administrator
Have any claims/suits been made within the last 5 years against the applicant?
If yes, please include information below specifying the date, description, amount paid and amount reserved.
Is the applicant aware of any circumstances which may result in any claim or suit being made, including
requests for medical records?
If yes, please include information below specifying the date, description, amount paid and amount reserved.
Has any insurance company declined, cancelled, or refused to renew any of the applicant's insurance?
If yes, please include information below describing why coverage was denied or cancelled.
Total Number of Residents
His/Her tenure at the facility
