ASSISTED LIVING FACILITY ( ALF )

LIABILITY INSURANCE PROGRAM


AGENCY:

LESTER KALMANSON AGENCY, INC &/OR MITCHEL KALMANSON

PO BOX 940008

MAITLAND, FL  32794-0008   USA

PH: 407-645-5000     FAX: 407-645-2820     WWW.LKALMANSON.COM


CLAIMS MADE APPLICATION FORM FOR PROFESSIONAL & GENERAL LIABILITY INSURANCE

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IMPORTANT

THIS IS NOT A BINDER!

INCOMPLETE AND UNSIGNED APPLICATIONS ARE NOT ACCEPTABLE

1)   PROPOSED EFFECTIVE DATE:    TERM:

2)     RETRO ACTIVE DATE:    (Date of inception at 12:01 am local standard time)

3)     Prior Acts coverage afforded:  NONE

4)   ERP offered (Extended Reporting period):  Yes

 

I   FACILITY INFORMATION:

5)  Name of facility:   

6)  D.B.A. :   

7)  Mailing address: 

8)  City:       State:       Zip:   

9) 

    IF OTHER:

10) Physical Location(s) Where operation(s) will take place at:

(Designated Insured Premises)

 

11) Contact Information:   Phone:         Cell:

      Fax:           E-mail:

 

12)  Requested Limits of Liability (per occurence / aggregate): 

IF OTHER :

13) Proposed Deductible:    $      (minimum deductible $5000)    [per claim B.I. / P.D. (Incl L.A.E.)]

 

14)  Is facility licensed by the State?   

       Expiration date of license:

15)  Ownership of Facility:

 

16)  Number of licensed ALF beds at this facility:       Average number occupied:

17)  Number of new residents in past 12 months:   

  

18)  Does the facility provide any health care services to non-residents?  

If yes, please explain: 

                                          

19)  Has the facility traded at a profit in the last 3 years?  

20)  Year facility was built:       Year of last renovation/upgrade:       

       Number of years in operation:           Number of floors: 

        Number of elevators              Number of separate buildings:   

      If more than one building, are transfers between buildings secure ? 

21)  Is this facility part of a chain (with common ownership/management)? 

        If yes, how many facilities in the chain ?       

22) Is this facility part of a CCRC?  

        If yes, number of SNF licensed beds         SNF occupied beds           IL units

       Are you utilizing the SNF licensed staff to support the ALF residents?  

 

II   CLAIMS / COMPLAINTS

23) Has the facility had any regulatory actions or formal complaints in the last 5 years? 

If yes, please provide details:

24) During the last 5 years, has the facility had any liability claims, or experienced any circumstances or incidents that could give rise to a liability claim? 

         If yes, please attach (FAX / MAIL) loss runs

III   RESIDENT PROFILE

25) Please indicate the percentage of residents in the following age groups:

      a) Less than 50 years:  %   b) 50-64 years: %  c)  65-80 years: %  d) Over 80 years: %

26) What is the average percentage of residents diagnosed with Alzheimer’s or Dementia? %

     Are the residents diagnosed with Alzheimer's or Dementia housed in a specific self contained unit?


 

IV   STAFF DETAILS

27) Administrator Name:   

       Number of years experience as administrator:  at this facility:         in career: 

 

28)  Are all employees subject to criminal background checks? 

       If yes, please indicate which of the following background checks are performed:

 DRUG SCREENING

 FINGERPRINTS

 SEXUAL OFFENDER REGISTRY

29)  Is the licensure status of all employees verified? 

30)  Are medical technicians used at this facility? 

      If yes, are they trained in state-approved programs? 

31) How many new employees (not including contract staff) were added to the nursing staff in the last   

      12 months?   Broken down into the following categories:

a)  RN’s:      b)  LPN/LVN:      c) CNA/Personal Care Aides: 

 

32) Please show the number of hours per day (total for all staff in category) of service rendered by

      each of the following:

a)  RN’s:       b) LPN’s/LVN’s:     c) CNA/Personal Care Aides:   

Non-certified direct care staff (e.g. personal care assistants):   

Medical technicians (if applicable):

 

33) Does the facility use contract (a.k.a. agency, registry) staff? 

       If yes, is evidence of insurance requested of them?  

34)  What percentage of all hours are provided by contract staff, broken down into the following categories?

a) RN’s: %  b) LPN/LVN: %  c) CNA/Personal Care Aides: %

d) Medical technicians:  %

V    BUILDING FIRE PROTECTION

35)  Please check which of the following apply:

      a) Common areas:

 HEAT DETECTORS

 SMOKE DETECTORS

 SPRINKLERS

      b) Hallways:

 HEAT DETECTORS

 SMOKE DETECTORS

 SPRINKLERS

      c) Resident rooms:

 HEAT DETECTORS

 SMOKE DETECTORS

 SPRINKLERS

 

36)  Please indicate how the fire detection system is routed:

37)  Please indicate which of the following describes the facility’s smoking policy:


VI   EXIT CONTROLS

38)  Please indicate which of the following exit controls are in place:

 CCTV

 WANDERGUARD (OR EQUIVALENT)

 OBSERVED EXIT

 ALARMS

 ELECTRONIC DOOR MONITORING DEVICE

39) Number of elopements at this facility in the last 12 months: 


VII   CURRENT INSURANCE INFORMATION

  a)  Current Professional/General Liability Insurer: 

  b)  Policy Period:  from     to:

  c)  Premium: $      

  d)  Limits: $       per occurrence   $ aggregate

  e)  Deductible/Self Insured retention: $

  f)  

  g)  If Claims Made, Retroactive Date:

MINIMUM PREMIUM OF $3,500 PLUS APPLICABLE FEES AND TAXES

40)  REMARKS:  (if any)

 

41)     A)  NOTE THIS POLICY WILL BE 35% MINIMUM EARNED AT INCEPTION

          B) ALL POLICY & INSPECTION FEES ARE 100% FULLY EARNED

          C) NO FLAT CANCELLATION PERMITTED

Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete or misleading information is guilty of a felony of the third degree.

 

PLEASE INITIAL AND DATE TO ACCEPT THE TERMS OF THE APPLICATION ( REQUIRED TO PROCESS APPLICATION )

INITIAL         DATE


AFTER SUBMITTING THE ONLINE APPLICATION,

DOWNLOAD, PRINT, AND COMPLETE THE "ALF SIGNATURE" & "TERRORISM INSURANCE COVERAGE" FORMS

BOTH FORMS REQUIRE WET SIGNATURES AND MUST BE MAILED TO OUR OFFICE TO PROCESS THE APPLICATION

 

 

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