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
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Adult Foster Care - Long Term Care APP

  • Applicant's Information

  • 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.
  • 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.
  • Declaration And Signature

    The 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will notify Underwriters and, at the sole discretion of Underwriters, any outstanding quotations may be modified or withdrawn.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.

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