Residential Care Facility Application

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Residential Care Facility Application

(note: All questions must be answered or application will be returned)

Effective Date Required:

This application requires the following attachments for all accounts:

  • 5 year, currently valued, hard copy loss runs
  • List of all incidents that could give rise to a claim
  • Current States License and most recent State Inspection (including responses to any deficiencies)
  • Copy of applicant’s brochure or website address (if applicable)
I. Applicant Information
1. Name(Legal Entity)
2. DBA
3. Federal ID Number
 
4. Website
5. Type of Entity
Other Entity
6. Contact Name
7. Phone
Fax
9. Mailing AddressStreet Address
City
State
ZIP
II. Policy Information
1. Does the applicant have insurance in place currently?(If yes, please provide the following information)
Current Carrier
Current Limits (GL/PL)
Expiring Premium
 
Current Retro-Date
Have any prior carriers non-renewed or cancelled your insurance policy?If yes, provide explanation.
2. Please select the General/Professional Liability Limit that you would like quoted
3. Please Select the Sexual Abuse Liability Sublimit that you would like quoted
4. Please select the requested GL/PL Deductible
5. Please provide the requested Retro Date (mm/dd/yyyy) for General/Professional Liability
III. Claims Activity & Procedures

Important Notice: All known claims and/or potential claim circumstances that could result in a claim are specifically excluded from coverage.Report all such claims and/or circumstances to your current insurer. Failure to disclose such claim, act, or circumstance may result in theproposed insurance being void and/or subject to rescission.

1. Are the Applicant and all professional employees licensed in accordance with applicable state and federal laws?
2. Has any license or accreditation ever been suspended, denied, or revoked?
3. Does any proposed insured have any knowledge of an event, circumstance, or occurrence prior to the effective date of the propose policy, or does and proposed insured foresee that a claim may be brought as a result of said event, circumstance, or occurrence?
4. During the past five (5) years, have any claims been presented to your current or prior insurance carrier or to you?
IV. Census & Exposures

1. Please provide the following (attach an additional sheet if necessary)*

Loc Number
Licensed Capacity(# of Beds)
Current Capacity(# of Beds)
Annual Receipts
# of Non-Ambulatory Residents*
Loc Number
Licensed Capacity(# of Beds)
Current Capacity(# of Beds)
Annual Receipts
# of Non-Ambulatory Residents*
Loc Number
Licensed Capacity(# of Beds)
Current Capacity(# of Beds)
Annual Receipts
# of Non-Ambulatory Residents*
2. Do you accept or retain any Alzheimer’s residents in your facility?
3. Is there an on-premises swimming pool/sauna?
V. Staffing

1. Please provide information on the following Key Staff:

Administrator's Name
# of Years In Current Position

2. Please provide Staffing Totals for other staff:

How many staff members are full time?
How many staff members are part time?
3. Do you require independent contractors and nurses to carry their own insurance?
4. Please indicate all methods used in HIRING all employees, including volunteers:
5. Please indicate all methods used in TRAINING all employees, including volunteers:
VI. Risk Management and Resident Safety
1. Is an assessment done on all residents prior to admission?
a. Does the assessment include fall risk?
b. Does the assessment include elopement risk?
c. How often are assessments performed after the initial assessment?
2. Is the family or guardian notified of any changes in condition?
3. Is there a specific transfer and discharge criteria?
4. Does your community have a no-smoking policy?
5. Please confirm that the following protocols are in place(check all that apply)
6. Are pets allowed?
VII. Life Safety & Property Protection
1. Please indicate what types of building protections are in place(check all that apply)
2. How often are fire drills conducted?
3. Does the applicant perform at least one fire drill each year during night hours (third shift)?
4. What types of cooking sources are used?(check all that apply)
5. Is there a fire suppression system for the cooking area?
6. Are the hoods/ducts cleaned by an outside vendor on a semi-annual schedule?




GENERAL FRAUD STATEMENT: Any person who knowingly and with intent to defraud any insurance company or another 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 fraudulent insurance act, which is a crime and subjects the person to criminal and (NY: substantial) civil penalties.

In the District of Columbia, Louisiana, Maine, Tennessee, and Virginia, and Washington insurance benefits may also be denied.

NOTICE TO COLORADO APPLICANTS: THIS NOTICE IS A PART OF YOUR APPLICATION FOR PROFESSIONAL LIABILITY INSURANCE: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado division of insurance within the department of regulatory agencies.

NOTICE TO FLORIDA APPLICANTS: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.

NOTICE TO HAWAII APPLICANTS: For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or benefit is a crime punishable by fines or imprisonment or both.

NOTICE TO OHIO APPLICANTS: Any person who, with intent to defraud or knowing the he/she is facilitating fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.

NOTICE TO OKLAHOMA APPLICANTS: WARNING: A person who knowingly and with intent to injure, defraud, or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony,

NOTICE TO OREGON APPLICANTS: Any person who knowingly and with intent to defraud or solicit another to defraud the insurer by submitting an application containing a false statement as to any material fact, may be violating state law.

NOTICE TO VERMONT APPLICANTS: Any person who knowingly and with intent to defraud any insurance company or another person files and application for insurance containing any materially false information or conceals for the purpose of misleading information concerning any fact material thereto, may be committing a crime, subjecting the person to criminal and civil penalties.

THE APPLICANT DECLARES THAT THE STATEMENTS SET FORTH HEREIN ARE TRUE. THE APPLICANT AGREES THAT IF THE INFORMATION SUPPLIED ON THE APPLICATION BY THE APPLICANT CHANGES BETWEEN THE DATE OF THE APPLICATION AND THE EFFECTIVE DATE OF INSURANCE, APPLICANT WILL IMMEADIATELY NOTIFY THE COPANY OF SUCH CHANGES AND THE COMPANY MAY WITHDRAW OR MODIFY ANY OUTSTANDING QUOTATIONS AND/OR AUTHORIZATION OR AGREEMENT TO BIND THE INSURANCE.



Applicant's Signature
Date


SIGNING THIS FORM DOES NOT BIND THE COMPANY TO ISSUE THIS INSURANCE. Application MUST be currently signed, completed and dated to be considered for quotation.


Please attach any documents you'd like to include with this application.This is not required.
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California License Number 0J13456

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