PCH Mutual - Residential Care Provider Insurance Renewal Application Final 10-2024

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 #*
Format: (000) 000-0000.
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.*

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

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
YesNo
If “Yes”, how many units?
Which location(s)?
Street, City, State and Zip Code
YesNo
If “Yes”, how many participants?
If “Yes”, how many participants?
Which location(s)?
Street, City, State and Zip Code
YesNo
YesNo
YesNo
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:

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

Cancelof
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
If “Yes” to above question, describe all off-site activities or excursions
Please describe in as few words as possible
Computer-basedWritten
YesNo
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*

Rows	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*

Rows	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

YesNo

Staffing Totals*

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

YesNo
If “No”, how are sleeping staff made aware of resident emergencies?
Please describe in as few words as possible
YesNo
YesNo
What is the average length of employment for all of your employees?*
YesNo
If "Yes", how many staff?
If “Yes”, how many staff?
YesNo
YesNo
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
YesNo
Building and Grounds at all locations
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
RentOwn

Location-specific Building Information*

Rows	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.

Cancelof
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.
YesNo
YesNo
YesNo
Firearms

Complete this section if there are firearms (rifles, handguns, etc.) on the premises of any location.
YesNo
YesNo
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
YesNo
YesNo
YesNo
Additional Coverage Options

Complete this section if you would like to request any additional coverages.
Excess Hired and Non-owned Auto Liability
YesNo
YesNo
How many employees (including active owners) do you have?
How many employees (including active owners) do you have?
YesNo
YesNo
YesNo
$300,000$500,000$1,000,000
Limited Physical Abuse and/or Sexual Abuse Coverage
YesNo
$500,000$1,000,000
Employer's contingent Liability

(WA, OH, NV, ND, WY Only)
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