(ALF)  ASSISTED LIVING FACILITY

SHORT FORM FOR QUOTING PURPOSES ONLY

AGENCY:     LESTER KALMANSON AGENCY, INC &/OR MITCHEL KALMANSON

                        P O BOX 940008

                       MAITLAND FL 32794-0008   U.S.A.

                 Phone: 407-645-5000     Fax: 407-645-2810     www.lkalmanson.com


IMPORTANT

THIS IS NOT A BINDER!

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 1)   PROPOSED EFFECTIVE DATE:         TERM:

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

 

3)  REQUESTED LIABILITY LIMITS: 

     IF OTHER:  (per occurence/aggregate)

 

4) PROPOSED DEDUCTIBLE:  $    (min ded $5,000 per claim B.I. / P.D. / Incl L.A.E.)

 

I   FACILITY INFORMATION

 

5)  Name of facility:        C/O

6)  Street address: 

7)  City:     State:      Zip:   

       Phone:    Cell:      Fax:  

       E-mail:

8)  Is facility licensed by the State? 

Expiration date of license:

 

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

 

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

        If yes, please explain: 

11)  Year facility was built:    

 

12) 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

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

If yes, please provide details.

 

14) 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 Fax / Mail loss runs.

 

 

III   RESIDENT PROFILE

15) Average percentage of residents diagnosed with Alzheimer’s or Dementia    %

16) Average residents diagnosed with Alzheimer’s or Dementia housed in a specific self-contained

      unit?     

 

IV   STAFF DETAILS

17) Administrator name:  

       Years experience as administrator:  at this facility:    in career:         

18)  Are medical technicians used at this facility?    

 

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

 

V    BUILDING FIRE PROTECTION

19)  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

 

VI  EXIT CONTROLS

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

 

 CCTV

 WANDERGUARD ( or equivalent )

 OBSERVED EXIT

 ALARMS

 ELECTRONIC DOOR MONITORING DEVICE

         

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

PRICING, TERMS AND CONDITIONS ARE SUBJECT TO RECEIVING A COMPLETED SIGNED APPLICATION.

 

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