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Protect You Better - Insurance Research Service

Rapid Quote

Please complete all sections of the following rapid quote form. The quote will be forwarded to you by e-mail shortly so be sure your e-mail address is correct.

First Name:
Last Name:
Name on License:
DBA:
Phone:
Email:
State:
Number of Beds:
What is the retro date for policy being quoted?
MM  DD  YYYY
Type of Entity:
Corporation
Sole Proprietor
Partnership
Non-profit
For Profit
Other

Effective Date of Policy: MM  DD  YYYY
Expiration Date: MM  DD  YYYY
Limit of Liability Requesting:
What Deductible?
Is there a swimming pool on the premises?
IF YES, is the pool fenced with a locked gate?
Does the pool have an alarm in it?
Are residents permitted to use the pool?
Are residents only permitted to use the pool with supervision?
Do you conduct criminal background checks on all employees?
Do you conduct reference checks on all employees?
Is third shift awake at all times?
What percentage of residents are wheelchair dependent?
Number of Independent Living Units?
Living Units State:
Do you have a designated staff member who administers medications?
Do you have a written policy for handling medications?
Have staff that administers medications completed a Medication Administration Course?
How many years experience in this or similar types of industry does management have?
How many deficiencies did you have on your last state inspection?
Have all the deficiencies been corrected?
Do you have a computer tracking system for your residents?
Do you want STOP GAP Coverage?
Do you have more than 40 employees?
Do you accept residents under age 18?


All quotes are subject to pre-approval of underwriting after review of a completed application, copy of your last state inspection report including any deficiencies and past claims history. This liability insurance program is only available to qualified licensed facilities and homes.