ASSISTED LIVING LIABILITY INSURANCE & BONDING 
Please click only once
Application.pdf
Application.pdf
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:

Street Address:

City:State:             Zip:

Entity Type:


 

Telephone:  Fax:   E-Mail:

Contact Name:
SECTION II - OPERATIONS
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: 


Page 1 of 2
CorporationLLCPartnershipSole ProprietorshipNot Yet DeterminedOther
YesNo
YesNo
Claims-MadeOccurrenceI Don't Know
YesNo
YesNo
YesNo
YesNo