ADULT DAY CARE GENERAL LIABILITY APPLICATION

Are you filling this out on behalf your client?

I am a(n)

Other

Name

Phone

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

Applicant’s Name

Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Location Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Web site Address

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

PROPOSED EFFECTIVE DATE :

Applicant is:

Limits Of Liability & Deductible Requested:

Rows
General Aggregate (other than Products/Completed Operation)
Products & Completed Operations Aggregate
Personal & Advertising injury (any one person or organization)
Each Occurrence
Damage to Premises Rented to you (any one Premise)
Medical Expenses
Other Coverage, Restrictions, and /or Endorsements :
Deductible

1. Number of years in business?

2. Is applicant licensed?

Is a license required by the state?

3. What is maximum number of clients permitted by license?

4. What is maximum number of clients on premises at any one time ?

Average daily attendance?

5. Please describe all the activities at this facility:

6. Indicate type of facility

7. Indicate type of counseling, if any, provided :

8. Is this an in-home facility?

If Yes, please explain:

9. Is there a swimming pool on the premises?

a. Number of pools ?

b. Are the pools fully fenced?

c. Are the rules posted?

d. Is there life-safety equipment at poolside?

e. Is there a diving board, platform, or slide?

f. Is a certified lifeguard or CPR certified attendant present at all times?

g. Are all swimming pools, wading pools, hot tubs and spas in compliance with the Virginia Graeme Baker Pool and Spa Safety Act?

10. Describe any special equipment on premises :

11. Any off-premises field trips?

If so, how many?

Describe:

12. Describe the building, including age, construction, number of stories, alarms, sprinklers, etc. :

13. Are there any non-ambulatory attendees?

If Yes: How many?

14. Are there any Alzheimer's afflicted adults?

If Yes: How many?

Are there anti-wandering devices on all the exits?

15. Describe how injuries or illnesses are handled :

16. Is there a doctor on staff or on call?

If Yes, please explain :

17. Does applicant have Workers Compensation coverage in force?

18. Ratio of caregivers to clients:

19. Total number of employees:

20. Are certificate of insurance obtained from all subcontractors?

If yes, minimum Limits required : $

Are you included as an additional insured on the independent contractors' policy?

Do you use uninsured subcontractors?

If yes, percentage of total subcontracted cost: %

21. Is there any overnight exposure?

If yes, please explain:

22. Is there any physical therapy exposure at this facility?

23. Is there any administering of medicine at this facility?

If Yes, Please explain

24. Has the applicant had any past or present allegations of physical /sexual abuse?

If Yes, Please explain

25. During the past three years, has any company ever cancelled, declined or refused to issue similar insurance to the applicant (Not applicable in Missouri)?

If Yes, please explain:

26. Does applicant have an accident and health policy?

If Yes, what limits ?

27. Does risk engage in the generation of power, other than emergency back-up power, for their own use or sale to power companies?

If Yes, Describe:

28. Does applicant have other business ventures for which coverage is not requested?

If yes, please explain and advise where insured:

29. Previous Insurer and Loss History: Indicate all claims or losses (regardless of fault and whether or not insured)or occurrences that may give rise to claims for the prior three years. Check if no losses in the last three years

Rows	YEAR	COMPANY	COVERAGE	PREMIUM	DATE OF LOSE	LOSSES PAID/RESERVED	DESCRIPTION OF LOSS
1
2
3
4

ADULT DAY CARE GENERAL LIABILITY APPLICATION

ANSWER ALL QUESTIONS - IF THEY DO NOT APPLY, INDICATE "NOT APPLICABLE"