Fillable LTCApplication Name of Applicant

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LTCApplication Name of Applicant

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The LTCApplication Name of Applicant form is 4 pages long and contains:

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  • 27 check-boxes
  • 212 other fields

Country of origin: US
File type: PDF

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AM-LTC.APP Page 1 of 4 5-12
ALLIED MEDICAL LONG TERM CARE
ASSISTED LIVING AND NURSING HOME
SUPPLEMENTAL APPLICATION
SUBMIT WITH ALLIED MEDICAL GENERAL APPLICATION
I. APPLICANT INFORMATION
1. Is your facility run by an outside management company?
Yes No
If Yes, provide name of company:
If Yes, does the outside management company have their own insurance coverage?
Yes No
2. Are you engaged in, owned by, associated with or involved in any other enterprises?
Yes No
If Yes, please explain:
3. Do you use a binding arbitration contract?
Yes No
If Yes, are ALL residents required to enter into a binding arbitration contract prior to moving in?
Yes No
II. RESIDENT ASSESSMENT
1. Is a nursing assessment conducted for new patients?
Yes No
If Yes, who completes pre-admission assessments? RN LPN Other (describe qualifications):
If Yes, does this assessment include evaluation of:
Full body skin breakdown/Decubitus ulcer Mobility limitations Cognitive
History of prior injuries Required assistance Current medications Wandering Risk
2. What is the system for identifying when a resident needs to
be transferred to another level of care (i.e., Nursing Home):
3. How often are residents reassessed?
4. Have you denied any admissions?
Yes No
If Yes, please indicate how many admissions were denied in the past two years and reason(s) for denial:
5. What system is in place to ensure timely reassessments?
III. RESIDENT CENSUS
Location 1
Location 2
Location 3
Number of licensed beds?
Number of occupied beds?
How many dementia residents (including Alzheimer’s)?
How many residents receiving skilled care?
How many residents receiving intermediate nursing care?
How many residents are independently ambulatory?
How many residents ambulate with assistance?
COLONY SPECIALTY
ALLIED MEDICAL – LONG TERM CARE
SUPPLEMENTAL APPLICATION
AM-LTC.APP Page 2 of 4 5-12
Location 1
Location 2
Location 3
How many residents are in a wheelchair all or most of the day?
How many residents are bedridden?
Minimum number of staff on duty during the third shift?
Indicate number of residents in each age range:
0-18
0-18
0-18
19-39
19-39
19-39
40-65
40-65
40-65
66+
66+
66+
IV. ELOPEMENT
1. Does your facility have a locked unit(s) for residents prone to wandering?
Yes No
If No, please explain:
2. What system is in use for residents prone to wandering?
3. Are all exit doors at all locations alarmed?
Yes No
If No, please explain:
4. How many residents have eloped from your facility in the last three years?
If any, please provide details:
5. What is the protocol or criteria for placing an alarm bracelet on a resident?
6. Is the family notified of the placement of an alarm bracelet on a resident?
Yes No
V. BEDSORE INFORMATION
Reporting Date: / /
1. Please indicate number of
bedsores:
Bedsores
Stage II
Stage III
Stage IV
Acquired in Facility:
Inherited from Another Location:
2. Please provide a description of the protocols/procedures in place for treating bedsores:
VI. MEDICATION ADMINISTRATION/FOOD CONTROLS
1 Is the unit dose medication system used by your facility?
Yes No
If No, what system is used?
2. Indicate who is responsible for administering medications to the residents in your facility:
Licensed Staff Medication Aide
3. Are medications kept under locked conditions?
Yes No
If No, please explain:
4. What controls/standards are in place to handle any special dietary needs of the residents?
COLONY SPECIALTY
ALLIED MEDICAL – LONG TERM CARE
SUPPLEMENTAL APPLICATION
AM-LTC.APP Page 3 of 4 5-12
VII. PREMISES INFORMATION (If more than three locations, please use separate page.)
Location 1
Location 2
Location 3
Type of construction:
Owned or leased:
Year built/updated:
Square feet:
Number of floors:
If multi-story building, on which
floor are non-ambulatory/
Alzheimer’s residents located?
Are there smoke detectors in all
bedrooms/hallways?
Yes No
Yes No
Yes No
If Yes:
Hardwired Battery
Hardwired Battery
Hardwired Battery
Fire alarm:
Central Local None
Central Local None
Central Local None
Is the building fully sprinklered?
Yes No
Yes No
Yes No
If No, what % is sprinklered?
%
%
%
VIII. STAFF
1.
Indicate for each category:
# of Years in Position at Facility
# of Years of Experience in Position
Administrator (attach resume)
Director of Nursing
Medical Director
2. Please indicate number of current staff at all locations:
1
st
Shift
2
nd
Shift
3
rd
Shift
Are all services
provided by
employees?
If No, what % of
services are provided
by non-employees?
If No, who provides
services?
RNs
Yes No
LPNs
Yes No
Nurse Aides
Yes No
Counselors
Yes No
Therapists
Yes No
3. Is the medical director employed by you?
Yes No
IX. LICENSING (please submit a copy of your current license)
1. Are you currently licensed for operations by the proper regulatory authorities?
Yes No
2. Is the license conditional?
Yes No
If Yes, please explain:
3. Has the license ever been revoked?
Yes No
If Yes, please explain:
X. STATE INSPECTION
1. Date of last State Inspection/Survey:
2. Total number of Deficiencies:
COLONY SPECIALTY
ALLIED MEDICAL – LONG TERM CARE
SUPPLEMENTAL APPLICATION
AM-LTC.APP Page 4 of 4 5-12
3. Number of Deficiencies (Nursing Homes only):
D, E & F:
G, H & J:
4. Corrective Action Plan accepted by State:
Yes No
If Yes, date accepted:
/ /
5. Number of complaints investigated by State the past two years:
6. Number of substantiated complaints:
Please attach a copy of the following with your submission:
Most recent state survey
Current license
Five years hard copy of current dated loss runs.
NOTICE TO APPLICANT
* Any person who knowingly and with intent to defraud any insurance company or other person files an application for
insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading,
information concerning any fact material thereto, may be committing a fraudulent insurance act, and may be subject to a
civil penalty or fine.
* Not applicable in all states
WARRANTY STATEMENT AND SIGNATURE:
The undersigned authorized officer of the Applicant declares that the statements set forth herein are the result of
said officer’s inquiry and, as such, are true, accurate and complete. The undersigned authorized officer agrees
that if the information supplied on the application changes between the date the application is signed and the
effective date of the insurance that is the subject of this application, such officer will immediately notify us of
such changes and we may withdraw or modify any outstanding quotations and/or authorization or agreement to
bind the insurance. Signing this application does not bind the Applicant to purchase, or us to issue, any
insurance policy.
Applicant’s Authorized Signature (of Principal, Partner or President)
Title
Date
SIGNING THIS FORM DOES NOT BIND THE COMPANY TO ISSUE THIS INSURANCE. Application MUST be
currently signed by a Principal, Partner or President of the Applicant acting as the authorized agent of the
person(s) and entity (ies) proposed for this insurance, completed and dated to be considered for quotation.
AGENT OR BROKER INFORMATION
Agency Name
Street Address
City
State
Zip Code
Producer Name
E-mail Address
Telephone #
Fax #
Producer Code (if applicable)
Producer License #
FL Register # (if applicable)
Surplus Lines License #
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LTCApplication Name of Applicant

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Completed 2 July 2020

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