Assisted Living Supplemental Application



Hanover Insurance Group

Assisted Living and Skilled Nursing Location Supplement

|Applicant’s Name | |Agency Name | |

|Mailing Address | |Expiration Date | |

|Location | |

----------------------------------------------------------------------------------------------------------------------------

GENERAL INFORMATION:

Website Address:

|Describe Facility Type (Adult Assisted Living, Intermediate Care, | |

|Skilled Nursing, Continuing Care, Other) | |

|# Years in Business | |# Years under current management | |

|Is the facility profit or not for profit | |% Rooms that are private pay | |

|# of Rooms | |

|Is there a manager on premises/duty 24 hours (Yes/No) | |If no, when | |

|Is there a preventative maintenance program (Yes/No) If yes, check type below | |

|Scheduled Maintenance for all key building systems | |Deferred Maintenance| |

| | |for all key building| |

| | |systems | |

|Are there any amenities such as swimming pools, spas, etc | |If yes, describe below: |

| |

PROTECTION:

|Smoke Alarms |In each unit (yes/no) | |Hardwired |

|Building Sprinklered (Yes/No) | |All floors (Yes/No) | |

|Check Type of sprinkler |Dry | |

|Do alarms ring into central security desk or nurses stations? | |

|Is smoking allowed in facility (Yes/No) | |If yes | |

| | |describe: | |

HIGH RISE

|# Enclosed Stairwells: | |

|Self Closing Doors (Yes/No) |Hallways | |Stairways |

|HVAC System |Equipped with Combustion Detector (Yes/No) | |

|Programmed for Automated Shutdown (Yes/No) | |Complete Exhaust(Yes/No) | |

|Emergency Notification System (Yes/No) | |If yes, describe: | |

|Are there more than one means of egress from each floor | |Written Evacuation plan posted in each | |

|(Yes/No) | |room (Yes/No) | |

COOKING FACILITIES

|Operated by: |Applicant | |Outside |

| | | |company |

|Has required fuel shutoffs (Yes/No) | |Covers all cooking and ventilation equipment (Yes/No) | |

|Cooking Equipment #: |# Deep Fat Fryers | |# Ranges | |

|Is application compliance with both NFPA Standard #96 and UL 300 Standard (Yes/No) | |

|Frequency of hood cleaning | |Frequency of duct work cleaning | |

|Professional hood and duct service firm used (Yes/No) | |Name | |

|Refrigeration maintenance agreement in place (Yes/No) | |Name | |

|Contract pest control services (Yes/No) | |Any health code violations in last 3 years (yes/no) | |

AUTOMOBILE:

|Does the applicant contract with outside company to transport residents (Yes/No) | |

|If yes, answer a, b and c below | |

| (a) Provide name of company | |

| (b) Does applicant require proof of insurance | |

|(c)What limit of insurance does applicant require | |

|Does applicant have owned have Autos (Yes/No) | |# of Autos | |

|Does applicant transport residents (Yes/No) | |

|Any vehicles with more than 8 passenger capacity (Yes/No) | |If yes, what is maximum seating | |

|Seating Capacity |VEH #1 | |VEH #2 |

|Does applicant review MVR’s for all drivers (yes/no) | |How frequent are MVRs reviewed for all drivers?| |

|Are employees with MVR violations allow to operate | |Does applicant drug test drivers (yes/no) | |

|vehicles (yes/no) | | | |

|Is operation radius of vehicles local only (Yes/No) | |If no, explain | |

|Is there a certified driver training course for new | |

|drivers (Yes/No) | |

|Are signatures obtained from both driver and trainer after satisfactory completion of driver training course | |

|(Yes/No) | |

|Are there written protocols for the loading and unloading wheel chairs (Yes/No). | |

|If yes, please include copy with submission | |

|Do volunteers transport residents (yes/no) | |

|Is there a preventative maintenance program performed for vehicles (yes/no) | |

|Do employees transport resident in their own vehicles (Yes/No) | |

|If yes, answer a and b below | |

|(a) Describe transportation activities | |

|(b) Does applicant require employees to maintain minimum limits of insurance| |

|(yes/no) If yes, specific limits | |

|Do volunteers operate any vehicles? (Yes/No) | |

Comments:

DECLARATION AND SIGNATURE

Authorized Entity Representative Designation

The person named herein is authorized and designated to give and receive any and all notices on behalf of the entity and all insureds from the entity or their authorized representative(s) concerning this insurance.

Named individual: ___________________________Title or Position: ____________________

Attestation

The authorized signer of this application represents to the best of his/her knowledge and belief that the statements and information set forth herein are true and include all material information. The authorized signer also represents that any fact, circumstance or situation indicating the probability of a claim or legal action now known to any entity official or employee has been declared, and it is agreed by all concerned that the omission of such information shall exclude any such claim or action from coverage under the insurance being applied for. Signing of this application does not bind the Hanover Insurance Group, Inc. to offer, nor the authorized signer to accept insurance, but it is agreed this application and any attachments hereto shall be the basis of the insurance and will be incorporated by reference and made part of the policy should a policy be issued.

Signature of Authorized Entity Representative_____________________________

Date: ______________

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download