Adult Foster Care - Long Term Care APP Long Term Care Facilities with 1-6 Beds (excluding Skilled Nursing Facilities) Underwritten by Underwriters at Lloyd's, London NEW! Adult Foster Care – Long Term Care APP PDF Download Adult Foster Care - Long Term Care APP Applicant's Information1) Name of Applicant:* Prefix First Last Suffix Date Established:* MM slash DD slash YYYY Physical Address of all locations seeking coverage:* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Mailing Address (if different than physical)* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code 2) Total number of occupied beds:*1234563) Name of Martgagee or Landlord requesting to be named as an Additional Insured* Prefix First Last Suffix Address of Mortgagee or Landlord requesting to be named as an Additional Insured.* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country For question #4 through #10, if the answer is "No", coverage cannot be bound per the terms and conditions of this program. If you desire an indication outside the program, please provide details for the "No" answers.4) Is the Applicant currently licensed as an Assisted Living Facility (level 4 or below), Personal Care Home or Independent Living Facility?* Yes No 5) Has the Applicant completed the most recent state mandated survey without any deficiencies or with a Plan of Correction that has been accepted by the state?* Yes No 6) Is the facility owner or a staff member on the premises at all times?* Yes No 7) Does the Applicant conduct wandering risk assessments upon admission?* Yes No 8) Are all exit doors alarmed at all locations?* Yes No 9) Is a nursing assessment conducted for new & current patients, including evaluation of decubitus ulcers, history of prior injuries, required assistance, disorientation and current medications?* Yes No 10) Do all physicians on staff, whether employed or contracted by the Applicant, carry their own Medical Malpractice insurance?* Yes No For questions #11 through #16 if the answer is “Yes”, coverage cannot be bound per the terms and conditions of this program. If you desire an indication outside the program, please provide details for the “Yes” answers.11) Has any resident(s) eloped from your facility in the last five (5) years?* Yes No 12) Have there been any complaints investigated by the State in the last two (2) years?* Yes No 13) Has any application for Professional Liability insurance made on behalf of the facility, ever been declined, or has the insurance ever been cancelled or renewal refused?* Yes No 14) Has any license or accreditation ever been suspended, denied or revoked?* Yes No 15) Has any claim ever been made against the facility or any of its employees?* Yes No 16) Is the Applicant aware of any circumstances which may result in any claim against the facility or any of the present or past Partners or Officers?* Yes No Declaration And SignatureThe undersigned declares that to the best of his/her knowledge, the statements herein are true. Signing of this Application does not bind the undersigned to complete the insurance, but it is agreed that this Application shall be the basis of the contract should a Policy be issued, and this Application will be attached and become a part of such Policy, if issued. Underwriters hereby are authorized to make any investigation and inquiry in connection with this Application, as they may deem necessary. It is warranted that the particulars and statements contained in the Application for the proposed Policy and any materials submitted herewith (which shall be retained in the files by Underwriters and which shall be deemed attached hereto, as if physically attached hereto), are the basis for the proposed Policy and are to be considered as incorporated into and constituting a part of the proposed Policy. It is agreed that in the event there is any material change in the answers to the questions contained herein prior to the effective date of the Policy, the Applicant will notify Underwriters and, at the sole discretion of Underwriters, any outstanding quotations may be modified or withdrawn. For purposes of creating a binding contract of insurance by the Application or in determining the rights and obligations under such a contract in any court of law, the parties acknowledge that a signature reproduced by either facsimile or photocopy shall be the same force and effect as an original signature and that the original and any such copies shall be deemed one and the same document. Name of Applicant:* (Please type full name in space provided)Title:* Applicant's Signature*(Please use your mouse on a PC or Mac, or your finger or stylus on a tablet or smartphone to sign your name.)Producer Name:* Retail Agency Name:* Date* MM slash DD slash YYYY EmailThis field is for validation purposes and should be left unchanged.
