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?

Corp.

LLC

Non-Profit

Year Founded

Years Under Same Mngt?

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

Funding source?

Private

SSI/SSP

Funding Agency(s)?

Estimated Annual Revenue?

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?

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

Yes

Please describe.

Is insurance in place at these other locations?

Location Details

Untitled

Is this location?	Building Description	Fire District	Street Address	Building	Exposure/Distance	Construction Type	Roof Type	Primary Heat	Alarm Type	Improvements - Year	Business Personal Property	Year Built	Distance From:	Stories	Square Footage	Basement?	Sprinklers?	% Coverage?	Location #:	Number of Beds by Resident Type:	Annual Residents by Age:	Occupany by Gender:	Any non-ambulatory?	Actions

There are no Locations.

Maximum number of locations reached.

Is 24/7 care offered?

Yes

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?

Resident Rooms

Inspection Freq.

By Who

How often?

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?

Workers Compensation

Staff Type

Type:	Employee - FT	Employee - PT	Annual Payroll	Actions

There are no Staff.

Maximum number of staff reached.

Limits of Insurance Required?

Vehicles and Transportation

Vehicles

VIN	Year	Make	Model	Coverage	Comp. Deductible	Collision Deductible	Does this vehicle have permanently attached equipment?	Value of Attached Equipment	# of Passengers	Is the vehicle equipped with an audible backup warning?	Do you allow drivers between 21 and 25 to operate this vehicle?	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

Please describe any ongoing training provided to drivers?

Wrapping Up

Additional Comments

Upload Files

Please include your most recent policy declaration pages, as well as five year loss runs.

Drop files here or

Max. file size: 12 MB.

Any other additional insureds required to be listed on the policies?

What is your insurance budget?

CPP

Auto

Umb/Ex

Total

Who is responsible for making the final decision?

Is there anything that would keep you from recommending us?

When do we need a quote by?

MM slash DD slash YYYY

Policy effective date?

MM slash DD slash YYYY

Next appointment date?

MM slash DD slash YYYY

Agent Requesting Quote?(Required)

Coverage(s) Needed:

Property

Liability

Auto

NOHA

Workers' Comp

Excess / Umb

Professional Liability

Cyber

D&O

EPLI

Crime

Abuse

Employee Benefits

Medical

Fiduciary

Quote Policy(s)

CPP

Management

Auto

Umb/Ex

Cyber

Accident

Flood

Package with:

Phly

AmTrust

USLI

Burns & Wilcox

XS Brokers

Management with:

Phly

Chubb

B&W

XS Brokers

WC with:

Accident Fund

Pie

Attune

Auto with:

Progressive

AmTrust

Phly

Cyber with:

Chubb

Phly

Amtrust

Property Deductible:

Other

Homework Needed:

Loss Runs

Policy Decs

Owner Resume

Temporary License

Inspection

Brochure / Program Overview

Other

Other:

Specialty Markets

Specialty Insurance

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