Assisted Living And Independent Living Facilities Application Page 6
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8PART VII - STAFFING
Location 1
Building construction (i.e., frame, brick)
Date built
Square feet
Number of floors
Yes
No
Smoke detectors in all
bedrooms/hallways?
Hardwired
Battery
or
Fire Alarm
Central
Local
None
Is the building fully sprinklered?
Yes
No
Yes
No
If not, what % is sprinklered?
%
Do all bedrooms/hallways
Yes
No
have smoke detectors?
Yes
No
Pool?
Yes
No
Fenced w / self-locking gate?
Does facility currently or, plan in the future to, sell intoxicating beverages to its residents, residents' family members and/or the general
Yes
public?
No
If "Yes", please explain below and provide a copy of your facility (ies) Liquor License, including a copy of the policy
declarations of your Dram Shop Liability coverage.
IMPORTANT NOTICE: THE COVERAGE OFFERED THROUGH LEWIS & CLARK RRG, INC. DOES NOT PROVIDE
LIQUOR LIABILITY COVERAGE AS RESPECTS FACILITIES WHO SELL INTOXICATING BEVERAGES. PLEASE
CONSULT WITH YOUR INSURANCE AGENT TO OBTAIN THE APPROPRIATE COVERAGE AS RESPECTS THIS
RISK.
PART VIX- SMOKING POLICIES AND PROCEDURES
Are any residents allowed to smoke unattended:
Yes
No
If yes, under what circumstances:
Are residents allowed to possess their own matches or lighters?
Yes
No
If yes, under what circumstances: If yes, under what circumstances:
Yes
Is smoking allowed in the resident's room?
No
Assisted Living Application-Uni-Ter Underwriting Management Corp (ed. 07-11)
Page 6 of 10
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