Assisted Living And Independent Living Facilities Application
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8Assisted Living and Independent Living Facilities Application
Professional & General Liability
Each question must be fully answered. If not applicable, please state "N/A"
(Complete a separate application for each location)
Deductable Requested: Requested Effective Date:
Limits Requested:
$250,000 / $500,000
$5,000
$500,000 / $1,000,000
$10,000
$1,000,000 / $3,000,000
WATERCOLOR PROGRAM OPTION:
$100,000 / $300,000
$2,500
Name of Applicant:
(Include full legal entity and all trade names. Attach a separate sheet if necessary
Mailing address:
City, State, Zip
Name of facility:
Physical address:
City, State, Zip
Telephone No.
Fax Number
Web Site:
Email address
Facility Type:
Assisted Living Facility
Independent Living Facility
Number of years this facility has been:
Operating
Owned by present owners:
Managed by present management company:
Current Administration:
Years of Experience
Years in this
Position
Name
in position
position at Facility
a. Organizational Structure of this facility:
Individual
Corporation
Partnership
Joint Venture
Other
LLC
For Profit
Not For Profit
b. Applicant's interest in facility is:
Owner
Lessor
Management Company
Tenant
Other
c. If management company, provide name and corporate address of owner
d. If the facility is managed by a separate management company, provide name and address:
Does your state require licensure to operate?
Yes
No
Has license ever been revoked or suspended?
Yes
No
Assisted Living Application-Uni-Ter Underwriting Management Corp (ed. 07-11)
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Parent category: Business