SENIOR LIVING SUPPLEMENTAL APPLICATION Note: All questions must be answered or application will be returned This application requires the following attachments for all accounts: Acords Five years currently valued loss runs Signed Supplemental Current Financial Statement (Over $100k in premium) Current state inspections including responses to any deficiencies Current License Incidents which may give rise to claim Brochures Resident Agreement (Incl. any arbitration) Evacuation Procedures for Non-ambulatory Residents The following are also required For CCRC s: Most recent Quality Indicator Profile Facility Diagram/Plot plan Provide a copy of the type of contract used- Life care, etc. SECTION I - NAMED INSURED Named Insured (Legal Entity) DBA: Mailing Address Name of Loss Control contact: Phone #: Email address: For Profit Not for Profit Religious Affiliated? Yes No Individual Partnership Corporation Other (describe) List all legal entities to be considered an insured, and their relation to the entity: List all subsidiaries of the named insured: Is the insured Operated by an outside Management Co.? Yes No If yes, how many years? Name of Management Company: # Of Years in Business under current ownership: Federal ID #: Website: Effective Date Requested: Date Quotation Desired: [X] Check all that apply to the applicant Senior Living Program 1 Last Update 12/17/2013
Hospital Based CCRC Medicaid Certified Medicare Certified Accredited by JCAHO Accredited by CARF/CCAC Other Accreditation: Current Insurance Information: Commercial General Liability Insurance Occurrence Claims Made Retro Date: Commercial Professional Liability Occurrence Claims Made Retro Date: Any change in name or operation since retro date? Yes No If yes, explain: SECTION II - CENSUS AND EXPOSURES Independent Living Retirement Community offering individual, fully functional apartments for residents in a community setting where meals may be shared, housekeeping and other social activities provided, do not receive health care services(adl s), administer own medications without assistance or reminders, staffed 24 hours. Assisted Living provides assistance with activities of daily living, housekeeping, medication and meals; coordination of outside health care services. Residents are usually ambulatory with minor disabilities that limit their independence. Memory Care Assisted Living provided within an alarmed unit dedicated to caring for residents with dementia, alzheimer diagnosis or other cognitive impairment. Skilled Nursing Provides 24-hour skilled care for residents who generally rely on assistance for most or all activities of daily living and procedures ordered by a physician. License Capacity Current Occupancy # Of Non- Ambulatory Residents** **Non-ambulatory means anyone who cannot self-evacuate to a fire safe area, even with verbal guidance, in the event of an emergency. Residents who use canes, wheelchairs or ambulatory support devices are considered ambulatory. o Respite Care Average visits/per month o Hospice Average visits/per month o Adult Day Care Average clients/per month (Please complete Section VII as well) 1. Does the insured serve any alcohol? Annual Receipts? 2. Will you accept residents with psychological disorders such as schizophrenia or bipolar disorders? Yes No Senior Living Program 2 Last Update 12/17/2013
3. What is the maximum percentage of residents you will accept with a diagnosed mental illness? 4. What is the average length of stay? 0-60 days 61-180 days Over 180 days 5. Do you accept residents under the age of 60? Yes No 6. # Medicaid Beds: # Medicare Beds: 7. Medicaid Reimbursement Rate: Private Pay Rate: DEMENTIA/MEMORY CARE 1. What percentage of your residents have a primary or secondary Dementia/Alzheimer diagnosis? 2. Do you have a separate secured wing or building designated for Dementia/Alzheimer s residents? Yes No 3. Do you allow residents with moderate to advanced dementia to reside and interact with residents who do not have Dementia? Yes No 4. What is the maximum level of Alzheimer s that you will retain in your facility (per the Global Deterioration Scale)? 5. Do you accept/retain residents who exhibit combative/violent behaviors? Yes No 6. How often are Dementia/Alzheimer s residents assessed to determine the level of care needed? DECUBITUS ULCERS/WOUND CARE 1. What is the highest stage pressure ulcer you will admit? Retain? 2. Will you retain residents with Decubitus Ulcers/Wounds with Stage III or IV unless the resident is in hospice? Yes No 3. Are there any residents currently receiving wound care? Yes No a. Stage of each b. Did they develop in house or were they admitted with them? 4. How many residents do you have who need to be repositioned every two hours? THIRD PARTY SERVICES 1. Please advise if any of the following services are provided by the insured or through a Third Party Home Health provider: A. Wound Care for stage 2, 3, or 4 decubitus ulcer Insured HomeHealth B. Catheter insertion and sterile irrigation Insured HomeHealth C. Gastronomy feeding Insured HomeHealth D. Postoperative/trauma recovery Insured HomeHealth E. Total Parental Nutrition Insured HomeHealth F. Intravenous/antibiotic/hydration/pain therapy Insured HomeHealth 2. If residents receive services by an outside Home Health Agency, Hospice, or Private Sitter Agency, is the contract between the resident and the Third Party Provider? Yes No 3. Do you provide care services for Independent Living residents (ADL s, assist or remind residents to take medications)? Yes No If yes, are the services provided under a separate home health or companion service? Yes No MEDICATIONS 1. Is there an on-site pharmacy? Yes No 2. If yes, is it used by anyone other than residents? Yes No 3. How often is an inventory of the narcotics performed? 4. How do you dispose of expired medications? Senior Living Program 3 Last Update 12/17/2013
5. How are the medications stored (i.e. med cart; separate, locked room)? 6. What type of medication packaging is used (bubble pack, samples, etc.)? Senior Living Program 4 Last Update 12/17/2013
SWIMMING 1. Is there an on-premise swimming pool/sauna? Yes No 2. If yes, is it used by families? Yes No If so, are waivers signed by the resident and family for use of the pool? Yes No Are children supervised at all times? Yes No 3. Is the pool/sauna fenced? Yes No 4. Is the fence locked when not in use? Yes No 5. Are you in compliance with the Virginia Graeme Baker Pool and Spa Act? Yes No 6. Is staff trained in water safety including CPR? Yes No SECTION III - STAFFING Key Staff Name Years of Employment in current position Medical Director Administrator Dir. Of Nursing # Of Years Experience 1. Does the Medical Director also act as the attending physician for any residents? Yes No 2. Have you credentialed your Medical Director? Yes No 3. # Of Key staff turnover (Medical Director, Administrator or DON) in the past five years 1 st Shift 2 nd Shift Night Shift Turnover Ratio Nurse Practitioner and Physician Assistants RN LPN/LVN C N A/Personal Caregiver Other staff/volunteers 4. Number of physicians on staff Employed or Independent Contractor? 5. Do you require independent contractors, nurses, physicians, and medical directors to carry their own insurance? Yes No What is the minimum limits of insurance required? Senior Living Program 5 Last Update 12/17/2013
SECTION IV - HIRING PRACTICES/TRAINING Please indicate all methods used in Hiring new employees (including volunteers): Criminal background checks (Federal & state, including sex-related crimes) Conduct personal interview Validate work history Validate education Drug Testing Reference checks Driving record 1. Do you obtain and verify nursing license upon hire? Yes No 2. Do you obtain and verify nursing assistant certification? Yes No 3. Do you regularly conduct background checks on current staff? Yes No 4. Do you do background checks on Third Party providers and/or subcontracted services? Yes No Please indicate all methods used for Training employees (including volunteers): Orientation & regularly scheduled in-servicing for all staff and employees? Formal training/procedures for incident reporting? Formal training for identifying, preventing and avoiding resident abuse? (Including resident on resident) Formal Training of Documentation of Resident Files SECTION V - RISK MANAGEMENT AND RESIDENT SAFETY 1. Is there a formal risk management program in place? Yes No 2. Is an assessment done on all residents prior to admission? Yes No A. Does the assessment include fall risk? Yes No B. Does the assessment include Elopement Risk? Yes No C. Does the assessment include Skin Assessment? Yes No 3. How often are assessments performed after the initial assessment? 4. Is the family or guardian and physician notified of any incident and change in condition? Yes No 5. Is there a specific admission and discharge criteria? Yes No 6. After a fall with a head injury or potential head injury, do you have a protocol in place to send residents to the hospital to be observed for a possible head injury? Yes No 7. Does the insured utilize a Refusal to Transport Form? Yes No 8. Does your community have a no-smoking policy? Yes No 9. Does the insured have security measures in place to prevent unauthorized entrances or elopement from the facility? (i.e.: Wanderguard, Camera Systems, Electronic Locks on Doors, Door Alarms, etc.) Yes No Senior Living Program 6 Last Update 12/17/2013
If yes, please describe they type of alarms in place including if they are audible alarm and/or go to pagers or central panel. Also, please describe when the alarms are set (i.e. 24/7 or 7pm to 7am) 10. How often are Elopement Drills conducted on each shift? 11. Do you have policies and procedures for elopement which include risk assessments, interventions and protocol for searches? Yes No 12. Have you had any missing residents/elopements in the past 12 months? Yes No If yes, please explain and provide what preventative measures have been put in place 13. Are there written emergency evacuation procedures and are they properly posted? Yes No 14. Are there advance arrangements for transportation to a temporary shelter? Yes No 15. Do you follow state guidelines for resident record retention after a resident leaves your community? Yes No 16. How long after a resident leaves your care do you maintain their records? 17. Do you have procedures in place to recover records promptly in the event they are needed for litigation defense years after a resident has left? Yes No 18. Confirm that the insured has the following written protocol in place (check all that apply): Incident reporting Skin Integrity Program, including regular assessments Mobility Management/Fall Prevention 19. Does the insured utilize Portable Enablers? Yes No Are they FDA compliant (less than 4 ¾ inch opening within the device and secured to the bed frame)? Yes No 20. Does the insured utilize binding arbitration in resident agreements? Yes No 21. Does the insured utilize shared risk and/or negotiated risk agreements? Yes No 22. Does the insured utilize resident & family surveys? Yes No 23. Are pets allowed on premise? Yes No SECTION VI HOME HEALTH (To be completed if the insured provides Home Health Services) 1. Please describe where Home Health Services are being provided? (Total of all Services must equal 100%) Private Homes % Clinics or Non-Private Homes % Doctor's Office % Hospitals % Owned Facility % Other(specify) % 2. Within your Owned Facility, how many Independent Living Residents do you provide Home Health services to? 3. Outside of your Owned Facility, what is the number of annual visits? Senior Living Program 7 Last Update 12/17/2013
4. Types of Services Provided: a. Companion Care c. Activities of Daily Living b. Skilled Nursing d. Hospice 5. Are Home Health Services provided by your employees or by independent contractors? 6. Is your Owned Facility licensed to provide Home Health Care/Companion Care Services? Yes No If yes, please provide copy of current license and state inspection. 7. Regarding Non-owned Auto, do you verify insurance coverage? Yes No a. If yes, what liability limit do you require? SECTION VII ADULT DAY CARE 1. Number of Average Daily Attendance 2. Average Age? If younger than 64, please explain: 3. Is this a licensed Adult Day Care Center? If yes, please provide copy of license and state inspection. 4. Is a physical examination performed by a physician required prior to admission? Yes No 5. What services are provided? 6. Any medical services provided? If yes, please explain: SECTION VIII - LIFE SAFETY / PROPERTY PROTECTION 1. Is the property built for occupancy? Yes No If no, indicate when and what renovations have been done: Roof Wiring Plumbing 2. Are there any surrounding exposures that may be considered hazardous? Yes No 3. # of stories? 4. Are all nonambulatory residents on the ground floor? Yes No 5. Are there at least two remote exits on each floor? Yes No 6. Indicate what types of building protections are in place (check all that apply) Sprinkler System Central Alarm Stations Smoke Detectors in resident rooms Fire extinguishers Battery backup 7. How often are fire drills conducted? Monthly Quarterly Annually 8. Does this include at least one fire drill per quarter during night hours? Yes No 9. Do you conduct fire drills as safely as possible within your State s regulations? Yes No Senior Living Program 8 Last Update 12/17/2013
10. Is there a building maintenance program? Yes No 11. What types of cooking sources are used? Gas Electric Deep Fat Fryer 12. Are wet chemical fire suppression systems used where deep fat fryers, griddles and broilers are present? Yes No 13. Is extinguishing equipment under a service contract? Yes No 14. Do you regularly clean the hood, ducts, filters, deep fat fryers and fans in the kitchen? Yes No 15. Are metal hoods equipped with noncombustible hood filters and explosion proof lights? Yes No SECTION IX - AUTOMOBILE 1. Do you provide regular transportation for residents? Yes No 2. Do you contract with a transport service for residents? Yes No If so, what kind? Ambulance Buses Vans 3. Do you have any owned autos? Yes No 4. Do employees or volunteers use their own vehicles on behalf of the insured? Yes No If yes, indicate frequency and details of usage If yes, does the insured verify insurance coverage and require state minimum limits or higher? 5. What is the maximum distance for regular transportation of clients? 6. What is the minimum and maximum ages of drivers allowed to drive passengers? 7. Do you check MVR s? Yes No How often? Do you have MVR criteria for drivers? Yes No If so, please describe criteria Is there training provided for proper loading and transportation of residents including nonambulatory residents? 8. Is there a vehicle maintenance plan? Yes No 9. Is there any personal use of any of your owned vehicles? Yes No If yes, percentage of personal use? ; Do youthful drivers, or spouse, have access to these vehicles? 10. Are all large capacity vehicles equipped with an audible backup warning device? Yes No Notes and Comments Senior Living Program 9 Last Update 12/17/2013
THE APPLICANT DECLARES THAT THE STATEMENTS SET FORTH HEREIN ARE TRUE. THE APPLICANT AGREES THAT IF THE INFORMATION SUPPLIED ON THE APPLICATION BY THE APPLICANT CHANGES BETWEEN THE DATE OF THE APPLICATION AND THE EFFECTIVE DATE OF INSURANCE, APPLICANT WILL IMMEDIATELY NOTIFY THE COMPANY OF SUCH CHANGES AND THE COMPANY MAY WITHDRAW OR MODIFY ANY OUTSTANDING QUOTATIONS AND/OR AUTHORIZATION OR AGREEMENT TO BIND THE INSURANCE. This application is understood to be an inducement to the issuance of a policy of insurance by the Company. The undersigned hereby authorizes the Company to obtain information necessary for evaluation in determining acceptability including but not limited to motor vehicle reports, credit reports and physical inspection. Applicant Statement and Signature: This application, loss information, and ACORD applications are understood to be an inducement to the issuance of a policy of insurance by the Company. The undersigned hereby: Authorizes Company to obtain information necessary for evaluation in determining acceptability including, but not limited to, motor vehicle reports, credit reports, and physical inspection. Warrants that all answers to questions are true and correct to the best of the applicant s knowledge and belief. Applicant Signature: Date: Senior Living Program 10 Last Update 12/17/2013