Commercial Insurance Underwriters, Inc. A Surplus Lines Agency www.ciusgf.com 901 E. Saint Louis St. #205 Springfield, MO. 65806-2537

Adult Day Care

Applicant Is: Individual  Corporation   Partnership    Joint Venture   Limited Liability Company  Other 

Other Type: 

A.  Number of years in business?   

B.  Is applicant licensed?    No Yes

        Is a license required by the state?    No Yes

C.  What is the maximum number of clients permitted by license?   

D.  What is the maximum number of clients on premises at any one time?   

E.  Please describe all the activities at this facility.

F.  Indicate type of facility:    Social    Medical    Mental

G.  Indicate type of counseling, if any, provided:    Financial    Medical

H.  Is this an in-home facility?    No Yes

    If yes, please explain:

I.  Is there a swimming pool on the premises?    No Yes

    If yes:

    1.    Number of pools?   

    2.    Are the pools fenced?    No Yes

    3.    Are the rules posted?    No Yes

    4.    Is there life-safety equipment at poolside?    No Yes

    5.    Is there a diving board, platform, or slide?    No Yes

    6.    Is a certified lifeguard or CPR certified attendant present at tall times?    No Yes

J.  Describe any special equipment on premises:

K.  Any off-premises field trips?    No Yes

    If so, how many?   

    Describe:

L.  Describe the building, including age, construction, number of stories, alarms, sprinklers, etc.:

M.  Are there any non-ambulatory attendees?    No Yes

    If yes, how many?   

N.  Are there any Alzheimer's afflicted adults?    No Yes

    If yes, how many?   

    Are there anti-wandering devices on all the exits?    No Yes

O.  Describe how injuries or illnesses are handled:

P.  Is there a doctor on staff or on call?    No Yes

    If yes, please explain:

Q.  Does applicant have Workers' Compensation coverage in force?    No Yes

R.  Ration of caregivers to clients:   

S.  Total number of employees:   

T.  Is there any overnight exposure?    No Yes

    If yes, please explain:

U.  Is there any physical therapy exposure at this facility?    No Yes

V.  Is there any administering of medicine at this facility?    No Yes

    If yes, please explain:

W.  Has the applicant had any past or present allegations of physical/sexual abuse?    No Yes

    If yes, please explain:

X.  During the past three years, ahs any company ever cancelled, declined, or refused to issue similar insurance to the applicant? 

        (Not applicable in Missouri.)    No Yes

Y.  Does applicant have an accident and health policy?    No Yes

    If yes, what limits?

Z.  Does applicant have other business ventures for which coverage is not requested?    No Yes

    If yes, please explain and advise where insured:

Previous Insurer and Loss History:  Indicate all claims or losses (regardless of fault and whether or not insured) or occurrences that may give rise to claims for the prior three years.

This application dos not bind the applicant nor the Company to complete the insurance, but it is agreed that the information contained herein shall be the basis of the contract should a policy be issued.

APPLICABLE IN THE STATE OF NEW YORK:

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, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.

FRAUD WARNING:

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 commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.

NAME AND TITLE:   

APPLICANT'S SIGNATURE:________________________________________________________                DATE:_______________   

AGENT NAME:        AGENT LICENSE NUMBER:   

(Applicable to Florida Agents Only.)

IOWA LICENSED AGENT:   

NAME AND PHONE NUMBER OF INDIVIDUAL TO CONTACT FOR INSPECTION/AUDIT:

IMPORTANT NOTICE

As part of our underwriting procedure, a routine inquiry may be made to obtain applicable information concerning character, general reputation, personal characteristics and mode of living. Upon written request, additional information as to the nature and scope of the report, if one is made, will be provided.

ANSWER ALL QUESTIONS - IF THEY DO NOT APPLY, INDICATE "NOT APPLICABLE"