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
1) 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 State ZIP Code
Mailing Address (if different than physical)*
Street Address Address Line 2 City State ZIP Code
2) Total number of occupied beds:*
3) 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 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 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.
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
Name
This field is for validation purposes and should be left unchanged.

Adult Foster Care - Long Term Care APP

Adult Foster Care - Long Term Care APP

Applicant's Information

Declaration And Signature