Residential Care Provider Insurance Renewal Application

General Information, Policies, and Procedures for all locations

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

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

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

Building and Grounds at all locations

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.

• 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

Residential Care Provider Supplemental Application

(Complete each section that applies to your facility. Any section which does not apply may be left blank)