ADDITIONAL LOCATION PROFESSIONAL & GENERAL LIABILITY INSURANCE APPLICATION FOR ASSISTED LIVING FACILITIES This application is only to be completed AFTER the Professional & General Liability Insurance Application for Assisted Living Facilities, located here. The purpose of this application is to submit additional locations for coverage. The submission of this form alone will not be sufficient as an application for coverage. If you have more than one additional location you are applying for coverage, you will be prompted after submission of this form to repeat this application. You may submit this application for as many additional locations as needed. Desired Effective Date:* MM slash DD slash YYYY SECTION I: APPLICANT INFORMATIONLegal Name of Applicant:* Phone Number:*Fax Number:Email:* SECTION II: FACILITY INFORMATIONFacility name:* Address:* 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 FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Facility Administrator’s Name:* and # Years Experience:* Number of years facility has been operating as a Long Term Care Facility:* Is the facility licensed by the state?* Yes No If yes, License # & Type: Std Std w/ LNS Std w/ ECC Std w/ LMHL Has your license ever been revoked, suspended, or restricted?* Yes No If yes, please explain: Number of Licensed Beds:* & # of Occupied Beds:* Does this facility have any other beds not included in the license?* Yes No If yes, please explain: Does this facility have any higher acuity (e.g. skilled nursing) beds?* Yes No If yes, please explain: Resident diagnosed w/ Alzheimer's:* Resident diagnosed w/ Psych Related:* Number of residents by group:Geriatric (65+):* Non-Geriatric (18-64):* Minors (<18):* Degree of care provided (check all that apply):* Bathing Dispensing of Medication Dressing Other (provide details) Are there any non-ambulatory residents?* Yes No If yes, how many are Bed Bound: If yes, how many are Cane Walkers: Who completes the resident assessments?* What system / protocol is used to identify when a resident needs transferred to a facility with a higher level of care?* How often do you re-assess your residents?* Any off-premise field trips?* Yes No If yes, please details & frequency: During the past 24 months, how many resident falls occurred while the resident was being assisted?* Were any residents insured as a result?* Yes No If yes, provide detailsDuring the past 24 months, how many elopements occurred at the facility?* Please provide details, including corrective measures, for any elopement:Were any residents injured as a result of an elopement occurring in the past 24 months?* Yes No Does the facility employ or contract with a licensed nurse for any services?* Yes No Does the facility employ or contract with a licensed nurse for any services?* Yes No Do you verify nursing licenses upon hire and annually?* Yes No Does the facility have awake staff on the premise 24 hours per day?* Yes No At a minimum, how many total staff hours per week does the facility employ?* Do you perform a criminal background check on current employees and potential employees?* Yes No The facility was built in what year:* and is a* Single Story Building Multi-Story Building Does the facility have a pool, Jacuzzi, or body of water on the premise:* Yes No If yes, provide details: Does the facility have a dog on the premise* Yes No If yes, provide details, including breed: Is smoking permitted inside the building:* Yes No If yes, provide details: Are residents allowed to possess lighters or matches?* Yes No What date was the facility last inspected / surveyed?* How many deficiencies were issued during the last inspection / survey?* Has the plans of correction been submitted to and approved by the state? Yes No Do you plan any facility expansions within the next 12 months* Yes No If yes, provide details:Last year's gross revenues:* SECTION III: REPRESENTATIONS & WARRANTIESThe undersigned authorized officer of the Applicant declares that the statements set forth herein are true to the best of my knowledge and that no material fact has been omitted or misstated. The undersigned authorized officer agrees that if the information supplied on the application changes between the date of the application and the effective date of the insurance, he/she (undersigned) will immediately notify the insurer of such change, and the insurer may withdraw or modify any outstanding quotations and/or authorization or agreement to bind the insurance. Signing of this application does not bind the Applicant to purchase or the insurer to provide the insurance. Acceptance of the Applicant by the company is required prior to quotation or binding of coverage or the issuance of a policy. It is agreed that this application and the reliance upon its contents shall be the basis of the issuance of a policy and shall be attached and made part of said policy. FRAUD WARNING: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD OR DECEIVE ANY INSURANCE COMPANY SUBMITS AN APPLICATION OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE, INCOMPLETE, OR MISLEADING INFORMATION MAY BE SUBJECT TO CIVIL OR CRIMINAL PENALTIES. NOTICE TO FLORIDA APPLICANTS: ANY PERSON WHO, KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY EMPLOYER OR EMPLOYEE, INSURANCE COMPANY, OR SELF-INSURED PROGRAM, FILES A STATEMENT OF CLAIM OR AN APPLICATION CONTAINING ANY FALSE OR MISLEADING INFORMATION IS GUILTY OF A FELONY OF THE THIRD DEGREE. I HAVE READ AND FULLY UNDERSTAND THE QUESTIONS AND MY ANSWERS ON THIS APPLICATION. UNDERSTAND THAT ANY OMISSION OR MISSTATEMENT OF ANY OF THE RESPONSES THAT ARE MATERIAL TO THE RISK ASSUMED (AS WELL AS ATTACHED TO THIS APPLICATION), MAY CAUSE THIS POLICY TO BECOME NULL AND VOID AND/OR MAY GIVE RISE TO RESCISSION OF THE POLICY. The Signatory hereby acknowledges that he/she is aware that the Aggregate Limit in the LTC policy may be reduced, and may be completely exhausted, by the costs of legal defense and, in such event, the Company shall not be liable for the costs of legal defense or for the amount of any judgment or settlement to the extent that such exceeds the limit of liability of this policy. The Signatory hereby further acknowledges that legal defense costs that are incurred shall be applied against the deductible amount. Should the signatory become aware of any change or omission relative to the information provided herein subsequent to the completion of this application and precedent to the effecting of insurance, the undersigned promissorily warrants that he will submit to the placed carrier's supplementary advice specifying such change or omission. Notwithstanding the immediate foregoing, however, the signatory further promissorily warrants that he will inform the placed carrier of any change or omission with respect to any answers given in this application at any time subsequent to the completion thereof, provided insurance has been effected. It is agreed that the duty imposed upon the signatory by virtue of the foregoing promissory warranties, shall be non-delegable. It is further agreed that this application shall be the basis of any insurance as may be subsequently effected by the placed carrier and that the placed carrier will rely upon the veracity of all responses thereto in causing such insurance to be effected. It is further understood and agreed that all representations and warranties made to the placed carrier also are made to the issuing carrier. It is finally agreed that the completion of this application neither obligates the Applicant to purchase insurance nor binds the placed carrier or the issuing carrier to affect insurance.Signatory statement agreement:* Yes, I have read the Required Fraud Warnings and further agree to the signatory statement. Signature*Name* First Last Date* MM slash DD slash YYYY CommentsThis field is for validation purposes and should be left unchanged.
