5- getitdoneright. now. all risks（5 - getitdoneright。现在。一切险）.docVIP

This application must be completed and signed by the applicant. In addition, the following must be attached to the application The following are required for all levels of care: Accord Applications: Property Auto General Liability Crime Inland Marine Electronic Data Processing Umbrella Signed Statement of Values LTC Business Interruption Worksheet (if applicable) Current valued loss reports of prior carriers Current audited financial statement (income, balance sheet, cash flow) with management notes Photo and facility diagram/plot plan Brochures and/or advertising materials Facility web site URL The following are required for Subacute/Skilled/Intermediate/Assisted Living Facility: Resumes for Administrator Director of Nursing (DON) Copy of facility license State survey reports - last 2 years (Include all statements of deficiencies and Corrective Action Plans) Substantiated Complaint Survey(s) and Corrective Action Plans if complaint is within the last 2 years The following are required for Subacute/Skilled Nursing Facility/Intermediate Care Facility: Current CMS Forms 671 Facility Staffing 672 Resident Census Copy of facility’s Skin/Wound Protocol Quality Indicator Report for the past two six-month periods Effective Date: Prior Carrier: Expiring Premium: $ Claims-Made Retro Date: I. Corporate/Parent Information 1. Corporate/Parent Name: Corporate Address: City: State: Zip: 2. Description of Corporate/Parent (check all that apply): For-Profit Not-for-Profit Religious Affiliated? Yes No Individual Partnership Corporation Hospital Affiliated CCRC JCAHO Accredited CCAC Accredited 3. Years parent company has been under present ownership: 4. Total number of facilities owned: 5. Is the parent company managed by a management company? Yes No If “Yes,” provide the name of management company: How many years in place with this management company? Provide a copy of the management contract. 6. List the Officers