PCH Mutual - Residential Care Provider Insurance Renewal Application 10-25-2022

Residential Care Provider Insurance Renewal Application

Name on License(s)*

DBA(s)

Mailing Address (Street, City, State and Zip Code)*

Contact Person*

Phone #*

Phone #

Check if Mobile

Email Address*

example@example.com

Website

If more than 5 locations, complete a second application for additional locations. There will be no coverage for operations at locations owned, leased, or operated by the insured that are not listed on submitted application.*

	Location Address	# of Licensed Beds	Facility Type
1.
2.
3.
4.
5.

Please select the limit of insurance requested:

Same limit as previous yearNew coverage limit

If you selected "New coverage limit" above, please insert the coverage limit requested below:

Please select one of the following limits: $100,000/$300,000 or $500,000/$500,000 or $500,000/$1,000,000 or $1,000,000/$1,000,000 or $1,000,000/$2,000,000 or $1,000,000/$3,000,000 or $2,000,000/$4,000,000

General Information, Policies, and Procedures for all locations

Are any of the above locations independent living (no med. assistance or care provided)?*

YesNo

If “Yes”, how many units?

Which location(s)?

Are any of the above locations adult day care to persons not living at the location?*

YesNo

If “Yes”, how many participants?

Which location(s)?

Do you offer any offsite home health or non-medical home care services?*

YesNo

Do you accept residents under the age of 18?*

YesNo

Do you expect to sell or change the management of any facility in the next twelve months?*

YesNo

Are all locations managed and operated by the licensee or employees of the licensee?*

YesNo

Have there been any changes in the operations and/or policies and procedures during the past 12 months?*

YesNo

If there have been any changes in the operations and/or policies and/or procedures, please explain

Has (1) an unexpected death; or (2) a fact, circumstance, event, or incident that might result in a claim on liability insurance occurred at any location in the past 3 years?*

YesNo

Has any license ever been denied, revoked, or suspended?*

YesNo

Has any fine, condition, restriction, or stop placement been imposed in the past 3 years?*

YesNo

Have you had any elopements (residents that have left the facility without your knowledge/permission) in the past 3 years?*

YesNo

Do you provide services other than assistance with daily living?*

YesNo

Do you have a written contract/agreement for your services with each one of your residents or their legal representative/Power of Attorney (POA)?*

YesNo

Do you use a Negotiated Risk Agreement?*

YesNo

Do you accept wanderers?*

YesNo

Do you conduct a wandering risk assessment upon admission?

YesNo

If you accept wanderers, check which of the following apply.

We use identification armbands on wanderersWe do not use identification armbands on wanderers

Are all residents assessed by a medical professional for cognitive decline or memory loss annually?*

YesNo

Are restraints used other than those ordered by a doctor?*

YesNo

Do you provide any offsite activities?*

YesNo

If you provide offsite activities, describe all off-site activities or excursions

Is your documentation for recording falls, monitoring medications, and changes in condition computer-based or written?

Computer-basedWritten

Do you follow current infection prevention and control measures?*

YesNo

If you answered “Yes” to following infection prevention and control measures, from what trusted source do you use?

MunicipalStateFederalOther

(For each location, the “Total of above lines” must be equal to the total number of residents currently at that location)

Residents’ Mental Capacity*

	Loc. #1	Loc. #2	Loc. #3	Loc. #4	Loc. #5
Number of dementia/Alzheimer’s residents
Number of developmentally disabled residents 55 & under
Number of developmentally disabled residents over 55
Number of mentally ill residents
Number of fully mentally functional residents
Total of above lines

(For each location, the “Total of above lines” must be equal to the total number of residents currently at that location)

Residents’ Physical Capacity*

	Loc. #1	Loc. #2	Loc. #3	Loc. #4	Loc. #5
Number of independently ambulatory residents
Number of residents who ambulate only with assistance
Number of residents confined to a wheelchair
Number of bedridden residents
Total of above lines

If any location above has bedridden residents, can they bear weight?*

YesNo

Staffing Totals*

	Loc. #1	Loc. #2	Loc.#3	Loc. #4	Loc. #5
Number of staff during the day
Number of staff overnight

Are overnight staff awake at all times?*

YesNo

If overnight staff are not awake at all times, how are sleeping staff made aware of resident emergencies?

Do you conduct reference checks on all new employees?*

YesNo

Do you conduct background checks on all new employees?*

YesNo

What is the average length of employment for all of your employees?*

Do you use a staffing agency to obtain your employees?*

YesNo

If answered “Yes” to using a staffing agency, how many staff?

Are staff members that administer medications trained in proper medication administration, handling, and safe-keeping?*

YesNo

Do you, your staff, or third-parties contracted with you provide services requiring a professional license?*

YesNo

If "YES" to providing professional services above, which services are provided that require a professional license?

Do you obtain a Certificate of Liability Insurance from all licensed medical professionals?*

YesNo

Are all exit doors alarmed?*

yesNo

Are there any firearms rifles, handguns, etc on the premises?*

YesNo

Are properly maintained smoke detectors located in all bedrooms and halls?*

YesNo

Do you have a fire inspection completed by a local fire department annually?*

YesNo

Do any of your locations have a swimming pool?*

YesNo

Do you or the owner of the premises carry property insurance on each building?*

YesNo

Location-specific Building Information*

	Loc. #1	Loc. #2	Loc.#3	Loc. #4	Loc. #5
Date of last fire extinguisher servicing
Distance to the nearest responding fire company
Distance to the nearest responding hospital or EMT

The application for this policy is incorporated and warranted as part of this policy. This insurance policy is being issued in reliance on the accuracy, truthfulness, and completeness of the application. Any inaccuracy, falsity, or omission, regardless of the nature, shall entitle us to rescind the policy. I declare that the information provided in this application is accurate, true, and complete and based on reasonable inquiry. I declare that each location currently complies and will comply with the rules and regulations set by state and federal law. I understand that if I willfully do not comply with these rules and regulations that coverage is null and void and any claims may be denied and premium returned. If the information supplied on the application changes between the date of the application and the effective date of the insurance, I will immediately notify PCH of any changes. In the event of any changes, PCH may withdraw or modify any outstanding quotations and/or agreement to bind the coverage. I must notify PCH of any changes in the operation of this business during the policy period, and failure to do so may result in cancellation of the coverage or denial of a claim. I hereby authorize PCH to obtain information necessary for the evaluation in determining acceptability, including, but not limited to, physical inspections and inquiries with the state licensing departments.

Signature

Clear

Printed Name and Title

Date

Please upload a copy of your state license and most recent annual inspection here.

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This application does not guarantee approval for insurance. PCH reserves the right to decline coverage. This application requires the following attachments:
Copy of state license for each location
Copy of the last state inspection for each location
Copies of any citations or notices of deficiency within the last 12 months

PCH Renewal Application (Version 10.25.2022)

Resident Censuses

Building and Grounds at all locations