PCH Mutual - Residential Care Provider Insurance Renewal Application Final 10

Residential Care Provider Insurance Renewal Application
Name on License(s)*
DBA(s)
Mailing Address*
Mailing Address Street
Mailing City*
Mailing Address City
Mailing State*
Mailing Address State
Mailing Zip*
Mailing Address Zip
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 Name	Location Address	# of Licensed Beds	Facility Type
1.
2.
3.
4.
5.

Please select the limits of insurance requested*

Same limits as previous policyNew coverage limits:
If you selected "New Coverage Limit" above, which limit do you desire?
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)?
Street, City, State and Zip Code
Are any of the above locations adult day care to persons not living at the location?*

YesNo
If “Yes”, how many participants?
If “Yes”, how many participants?
Which location(s)?
Street, City, State and Zip Code
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?
Are all locations managed and operated by the licensee or employees of the licensee?*

YesNo
If answered "NO" to above question, please attach a copy of the management agreement or contract:

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

YesNo
If you answered “YES” to the above question, 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
If you answered "YES" to any of the above questions, please provide a detailed explanation and upload it here.

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Do you have a written contract or 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 (not applicable in DE, IN, NJ, OH, WI or WA)

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
Do you provide any off-site activities or excursions to the residents?*

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

YesNo
If “Yes” to above question, describe all off-site activities or excursions
Please describe in as few words as possible
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 providing infection prevention and control measures above, from what trusted source?

MunicipalStateFederalOther
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

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?
Please describe in as few words as possible
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?
If “Yes”, how many staff?
Are the staff members that administer medication 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 you answered "YES" to providing professional services above, what services are provided which require a professional license?

Skilled Nursing Care by You/StaffSkilled Nursing Care by ContractorNo Skilled Nursing Care provided by either staff or contractedMedical Doctor Care by You/StaffMedical Doctor Care by ContractorNo Medical Doctor Care provided by either staff or contractedHospice, Physical Therapy, Wound care - You/staffHospice, Physical Therapy, Wound care - ContractorNo Hospice, Physical Therapy, Wound careOther services by You/staffOther services by contractor
If Other for above, please explain
Do you obtain a Certificate of Liability Insurance from all licensed medical professionals?

YesNo
Building and Grounds at all locations
Are all exit doors alarmed?*

YesNo
Are there any rifles, pistols, or guns on the premises?*

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

YesNo
Do you have a fire inspection by a local fire company 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?*

RentOwn

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)

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
Please upload a copy of your most recent annual state inspection report, license, citations or notice of deficiencies and plan of correction.

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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 are wheelchair bound or bedridden.
Are all wheelchair-bound/bedridden residents on a ground level floor?

YesNo
Are at least 2 exits level with the ground or ramped?

YesNo
Is a negotiated risk agreement completed on wheelchair-bound/bedridden residents?

YesNo
Firearms

Complete this section if there are firearms (rifles, handguns, etc.) 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 swimming pool on the premises of any location.
Which locations have a pool?
Street, City, State and Zip code
Is pool use only permitted with supervision?

YesNo
Is the pool fenced with a locked gate?

YesNo
Are all doors leading to the pool alarmed?

YesNo
Additional Coverage Options

Complete this section if you would like to request any additional coverages.
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?
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 $300,000CSL, $250,000/500,000, or more?

YesNo
Are Motor Vehicle Records of all 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?
How many employeesdo you have at all locations?
Signature

Clear
Printed Name and Title
Date

MonthDayYear
Date
Should be Empty:

Resident Censuses

Wheelchair-bound/Bedridden

Firearms

Pools

Additional Coverage Options

Excess Hired and Non-owned Auto Liability

Limited Physical Abuse and/or Sexual Abuse Coverage

Employer's contingent Liability