PCH Mutual - Residential Care Provider NB PLGL Application Final 10

Residential Care Provider Professional and General Liability Insurance 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
Number of years in operation
Number of Years in Operation*
If in operation less than 1 year, please attach a resume or a sheet with your prior experience.

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FEIN*
Effective Date Requested

MonthDayYear
Date
Type of Entity*

IndividualLLCCorporationPartnership/Joint VentureOther

Location Address:*

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

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 a submitted application.
Limits of Insurance Requested (Per Claim/Aggregate)

$50,000/200,000$100,000/300,000$500,000/500,000$500,000/1,000,000$1,000,000/1,000,0001,000,000/2,000,000$1,000,000/3,000,000$2,000,000/4,000,000
General Information for all locations
Are any of the above locations independent living (no med. assistance or care provided)?*

YesNo
If "Yes", how many units?
If “Yes”, how many units?
Which location(s)?
Do any of the above locations provide adult day care to persons not living at the location?*

YesNo
If "Yes", how many participants?
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 any residents under the age of 18?*

YesNo
Do you expect to sell or change the management of any facility within the next 12 months?*

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

YesNo
If you answered "No" to the above question, please upload a copy of the Management Agreement.

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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
(if answered "Yes" to any of the above questions, please attach a detailed explanation on a separate form here.

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Do you or your owners/members own or operate any residential care facilities, independent living facilities, or similar businesses not listed on this application?*

YesNo
If you answered yes to the above question, please provide the name, address and type of business for all businesses on a separate sheet and attach here.

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Is there a professional medical assessment obtained prior to admission?*

YesNo
How often are residents reassessed by a medical professional?
Do you have a written contract/agreement for services with each one of your residents or their legal representative/Power of Attorney(POA)?*

YesNo
Do you use a Negotiated Risk Agreement? (not applicable in DE, IN, NJ, OH, WI, & WA)*

YesNo
Do you require a signed release in order to release records pertaining to the resident?*

YesNo
Does the resident or legal representative/POA sign a release for emergency medical treatment?*

YesNo
Have you had any new residents within the past 90 days?*

YesNo If “Yes”, how many?
If “Yes”, how many?
Do you conduct a tour of the facility and review procedures with new residents and their legal representative/POA?*

YesNo
Do you accept wanderers?*

YesNo
If "Yes", are identification armbands used?

YesNo
Do you conduct a wandering risk assessment upon admission?*

YesNo
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 off-site activities or excursions to the residents?*

YesNo
If “Yes”, describe all off-site activities or excursions
Please describe in as few words as possible
Resident Censuses
(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
Policies and Procedures at all locations
Does the facility have a written plan for missing residents (missing resident protocol)?*

YesNo
Does the facility have a sign out policy in place?*

YesNo
Does the facility have a written physical and sexual abuse prevention policy?*

YesNo
Does the facility have a written procedure for resident falls which includes communication with family and medical personnel and written documentation of this action?*

YesNo
Do you have written policies and procedures regarding care and treatment of residents that are easily accessible by your staff?

YesNo
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 “Yes” to "following current infection prevention and control measures", from what trusted source?

MunicipalStateFederalOther

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 “No”, 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 “Yes”, how many staff?
Do you have an employee training program?*

YesNo
Are the 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
Other professional services by you/staff
Other professional services by contractor
Do you obtain a Certificate of Liability Insurance from all licensed medical professionals?

YesNo
If "yes" to above questions, what services are provided which require a professional license?

Skilled Nursing - You/StaffSkilled Nursing - ContractedSkilled Nursing - NeitherMedical Doctor - You/StaffMedical Doctor - ContractedMedical Doctor - Neither 7Hospice, Physical Therapy, Wound Care - You/StaffHospice, Physical Therapy, Wound Care - ContractorHospice, Physical Therapy, Wound Care - Neither
If either of the "other services", please explain
Please describe in as few words as possible
Building and Grounds at all locations
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 the locations have a swimming pool?*

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

YesNo
Do you own or rent the building(s) for each location

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 (In Miles)
Distance to the nearest responding hospital or EMT (In Miles)

Additional Insureds

Complete this schedule if any Additional Insured’s need to be named on your policy

	Name and Mailing Address of Additional Insured	Interest	Loc.

Please attach a copy of your most current annual state inspection and license here.

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Additional Coverage Options
PCH Mutual offers several additional coverages to meet your needs. Coverages can be reviewed on the Additional Coverage Options section of the Residential Care Provider Supplemental Application. Please consult your agent/broker with any questions on these coverages.
Do you desire any of the coverages shown on the Additional Coverage Options section of the Residential Care Provider Supplemental Application?

YesNo
If “Yes”, attach the completed Residential Care Provider Supplemental Application.

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*

MonthDayYear
Date
- 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
- Copy of your current insurance policy(ies) if applicable
- 3 years of currently valued loss runs from existing and previous insurance companies for each location if applicable or no known losses letter
- If new venture, supply 3 years of relevant job experience or resume
Producer Name
Agency/Broker
Agency Address
Email Address
example@example.com
How did you hear about us?

AssociationMailerInternet SearchReferral
Residential Care Provider Supplemental Application

Complete each section that applies to your facility. Any section which does not apply may be left blank
Name on License
Wheelchair-bound/Bedridden

Complete this section if any location has more than 50% of residents that arewheelchair-bound and/or bedridden.
Are all wheelchair-bound/bedridden residents on a ground level floor?

YesNo
Are at least two exits level with the ground or ramped?

YesNo
Is a Negotiated Risk Agreement completed on wheelchair-bound/bedridden residents?

YesNo
Rifles, Pistols or Guns

Complete this section if there are rifles, pistols or guns on the premises of any location.
Are all rifles, pistols or guns kept in a locked gun cabinet/safe?

YesNo
Is the gun cabinet/safe in a locked room?

YesNo
Is all ammunition stored separately from the rifles, pistols or guns in a locked container?

YesNo
Pools

Complete this section if there is a pool on the premises of any location
Which Locations have a pool?
Is pool use only permitted with supervision?

YesNo
Is the pool fenced with alocked gate?

YesNo
Are all doors leading to the pool alarmed?

YesNo
Additional Coverage Options

Complete this section if would like to request any additional coverages. Consult your agent/broker for questions on these coverage options
Excess Hired and Non-owned Auto Liability
Do you want Excess Hired and Non-owned Auto Liability coverage?

YesNo
Do you currently have a Commercial Auto policy in place?

YesNo
How many employees (including active owners) do you have?
Are all individuals driving their personal autos on behalf of the facility required to carry Personal Auto Liability limits of $300,000 CSL, $250,000/500,000, or more?

YesNo
Are Motor Vehicle Records ofall employees reviewed for acceptability pre-hire and annually thereafter?

YesNo
Do you or your employees transport residents?

YesNo
What limit of Excess Hired& Non-Owned Auto Liability do you want?

$300,000$500,000$1,000,000
Limited Physical Abuse and/or Sexual Abuse Coverage
Do you want increased limits for Limited Physical Abuse and/or Sexual Abuse Coverage above the amount already included in your policy?

YesNo
What limits are requested?

$500,000$1,000,000
Employer’s Contingent Liability

WA,OH, NV, ND, WY Only
Do you want Employer’s Contingent Liability?

YesNo
How many employees do you have at all locations?
Signature

Clear
Printed Name and Title
Date

MonthDayYear
Date
Would you like to apply for Worker's Compensation coverage?

(After clicking the hyperlink, please return and submit this application)

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Should be Empty:

Resident Censuses

Additional Insureds

Additional Coverage Options

Residential Care Provider Supplemental Application

Wheelchair-bound/Bedridden

Rifles, Pistols or Guns

Pools

Additional Coverage Options

Excess Hired and Non-owned Auto Liability

Limited Physical Abuse and/or Sexual Abuse Coverage

Employer’s Contingent Liability