ADULT DAY CARE GENERAL LIABILITY APPLICATION

ADULT DAY CARE GENERAL LIABILITY APPLICATION
Are you filling this out on behalf your client?

YesNo
I am a(n)

Insurance BrokerReal Estate AgentLender / Mortgage BrokerOther
Name*
Phone*
Please enter a valid phone number.
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.
PROPOSED EFFECTIVE DATE :

MonthDayYear
Applicant is:

IndividualCorporationPartnershipJoint VentureLimited Liability CompanyOther
ANSWER ALL QUESTIONS - IF THEY DO NOT APPLY, INDICATE "NOT APPLICABLE"

Limits Of Liability & Deductible Requested:


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?

YesNo
Is a license required by the state?

YesNo
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

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

FinancialMedical
8. Is this an in-home facility?

YesNo
If Yes, please explain:
9. Is there a swimming pool on the premises?

YesNo
a. Number of pools ?
b. Are the pools fully fenced?

YesNo
c. Are the rules posted?

YesNo
d. Is there life-safety equipment at poolside?

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

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

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

YesNo
10. Describe any special equipment on premises :
11. Any off-premises field trips?

YesNo
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?

YesNo
If Yes: How many?
14. Are there any Alzheimer's afflicted adults?

YesNo
If Yes: How many?
Are there anti-wandering devices on all the exits?

YesNo
15. Describe how injuries or illnesses are handled :
16. Is there a doctor on staff or on call?

YesNo
If Yes, please explain :
17. Does applicant have Workers Compensation coverage in force?

YesNo
18. Ratio of caregivers to clients:
19. Total number of employees:
20. Are certificate of insurance obtained from all subcontractors?

YesNo
If yes, minimum Limits required : $
Are you included as an additional insured on the independent contractors' policy?

YesNo
Do you use uninsured subcontractors?

YesNo
If yes, percentage of total subcontracted cost: %
21. Is there any overnight exposure?

YesNo
If yes, please explain:
22. Is there any physical therapy exposure at this facility?

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

YesNo
If Yes, Please explain
24. Has the applicant had any past or present allegations of physical /sexual abuse?

yesNo
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)?

YesNo
If Yes, please explain:
26. Does applicant have an accident and health policy?

YesNo
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?

YesNo
If Yes, Describe:
28. Does applicant have other business ventures for which coverage is not requested?

YesNo
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

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

Should be Empty:

ADULT DAY CARE GENERAL LIABILITY APPLICATION

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