Professional & General Liability Insurance Residential Care, Assisted Living and Independent Living Pre-Submission Questionnaire

Complete a separate questionnaire for each facility.

Number of Facilities:
Member/Insured Name:
Address (City, State, ZIP):
Contact Name:
Type of Facility:
Skilled Nursing Facility Residential Care
Assisted Living Independent Living
Number of Licensed Beds:
Skilled Nursing Facility Residential Care
Assisted Living Independent Living
   
What is your normal anniversary date?
Is this facility currently insured? Yes       No
If no, last date of coverage:
Please provide your desired coverage date:
Current number in occupancy:
Are there any special programs or units? Yes       No
Check if applicable:
Alzheimer's and Dementia Psychiatric
Pediatric Home Health
Hospice Other
Current number of residents under age 65:
Length of current ownership:
Number of affiliated facilities not presented for review:
How many years has your Administrator (ADM) worked in his/her position at your facility?
How many years has your Director of Nursing (DON) worked in his/her position at your facility?
Any open claims with reserves of over $25K? Yes       No
If yes, list total reserves for each claim in the last 5 years:
Any closed claims over $25K in the last 5 years? Yes       No
If yes, list total paid for each claim in the last 5 years:
Does the facility have any current de-certification action, enforcement action, monetary penalties or uncorrected / unresolved substandard care issues? Yes       No
Have there been any substanitiated (or pending results of investigation) abuse allegations in the past 12 months? Yes       No
Has the facility filed or considered filing for bankruptcy in the last 3 years? Yes       No
Publicly traded stock corporation? Yes       No