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Contact Name

First Last

Position

Phone

Business Legal Name

DBA?

Mailing Address

Street Address Address Line 2 City State ZIP Code

Same as Physical Address?

Yes

Physical Address

Street Address Address Line 2 City State ZIP Code

Organization Type?(Required)

For-Profit

Non-Profit

Year Founded(Required)

Years Under Same Mgnt?

Number of Homes?(Required)

Website

FEIN #

SIC #

Current Insurance Information

Do you currently have insurance?

Yes

Why not?

Last month/date you had insurance?

Who are you insured with?

When does your insurance renew?

MM slash DD slash YYYY

Other Insurance Company

How long have you been with your agent?

Any problems with your current insurance?

Have you had any claims in the last 5 years?

Yes

Please describe the claims and the amount paid on the claim(s):

What is prompting you to review your insurance?

General Information

Primary funding source?

Private

SSI/SSP

Are all facilities licensed through the state?

Yes

Has your license ever been suspended, revoked, or placed under conditional status OR claims of negligence?

Yes

Please explain?

List any association memberships or affiliations?

Do you operate any other locations not included on this application?

Yes

Please describe.

Is insurance in place at these other locations?

Home(s) Information

Untitled

Is this location?	Number of beds?	Street Address	How many beds are Alzheimer's?	How many beds are Aged?	Improvements - Year	Hidden Field: Business Name	Hidden Field: Email	Actions

There are no Homes.

Maximum number of homes reached.

Facility Information

Resident unauthorized leave prevention?

Check all that apply.

Exit doors locked

Wristband sensor with alarm

Exit doors alarmed

How often are residents checked to ensure they're at the facility?

How are residents separated?

Does a physician screen clients prior to admission?

Yes

Are residents responsible for their own basic personal care?

Example: Bathing, dressing, eating, restroom aide.

Yes

Do you allow physical restraint?

Yes

Which non-violent crisis intervention protocol is used?

Which method of de-escalation is used?

How do you provide for resident privacy and security?

What procedures are in place for clients allowed to leave without supervision?

On average, how many visits per month are made by a caseworker?

Resident Rooms

Inspection Freq.

By Who

How often?

Is there a written plan for supervising staff when interacting with clients on and off premises?

Yes

Are security cameras monitoring operations and residents?

Yes

Are resident's door ever locked from the outside?

Yes

Are residents allowed to cook their own meals?

Yes

How?

Private

Common cooking area

Is there a pool?

Yes

Who uses the pool?

Check all that apply.

Visitors

Staff

Clients/Residents

Is the pool fenced with a self-locking gate?

Yes

Height of the fence?

Is there a diving board?

Yes

Is there trained staff on water safety?

Yes

Abuse Prevention

Do you run criminal background checks, including sex/child abuse related crimes, before an employment offer?

This includes employees and volunteers.

Yes

Do you have a crisis plan for dealing with an incident of abuse?

Yes

Is there formal training on child/sexual abuse?

Yes

Are closed door one-on-one meetings prohibited?

Yes

How do you ensure no relationship occurs between staff and clients?

Have any incidents resulted in an allegation of sexual abuse?

Yes

Was the case taken to trial?

Yes

Damages paid?

Human Resources

Staff Type

Type:	Employee - FT	Employee - PT	Contracted - PT	Contracted - PT	Annual Payroll	Other	Actions

There are no Staff.

Maximum number of staff reached.

Do you have written job descriptions for each employee?

Yes

Is drug testing conducted?

Yes

Do you train and require all staff to report incidents, in writing, and do you investigate each incident?

Yes

Financials

Annual Revenue:

Estimated Current Fiscal Year

Previous Fiscal Year

Do you offer a retirement plan?

Yes

Plan Details

Name

Established

Assets

Type

Participants

Administrator

Do you file a Form 5500 each year?

Request a copy of most recent filing.

Yes

Why not?

Is your organization more than 25% owned by private equity?

Yes

Name of the firm?

Any mergers or operations under another name in the last five (5) years?

Yes

Please explain

Vehicles and Transportation

Vehicles

Year	Make	Model	Actions

There are no Vehicles.

Maximum number of vehicles reached.

Are all vehicles registered to the organization?

Yes

Please Explain

Do employees or volunteers use their personal vehicles for business?

Yes

Describe Use

How many use their own vehicles for business use?

Full Time - Driving over 20 hours per week Part Time - Driving up to 20 hours per week

Full Time

Part Time

Volunteers

Do you run MVRs on employees?

Yes

How often?

Do you require employees and volunteers to carry and show evidence of personal auto insurance?

Yes

Do you provide transportation services?

Yes

Do vehicles equipped for wheelchairs have tie-down belts?

Yes

Do you have a formal maintenance and safety training program in place?

Yes

Please describe any ongoing training provided to drivers?

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