Hanover Insurance Group

Assisted Living and Skilled Nursing Location Supplement

Applicant’s Name / Agency Name
Mailing Address / Expiration Date
Location

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GENERAL INFORMATION:

Website Address:

Describe Facility Type (Adult Assisted Living, Intermediate Care, Skilled Nursing, Continuing Care, Other)
# Years in Business / # Years under current management
Is the facility profit or not for profit / % Rooms that are private pay
# of Rooms / Avg Room Rate (Monthly rate for assisted living, daily rate for nursing) / Average Occupancy %
# of continuous years application has maintained a profit
Is there a manager on premises/duty 24 hours (Yes/No) / If no, when
Is there a preventative maintenance program (Yes/No) If yes, check type below
Scheduled Maintenance for all key building systems / Deferred Maintenance for all key building systems / Strategy of no Maintenance prior to repair
Are there kitchenettes in guest rooms (Yes/No) / If yes, describe
Are there any amenities such as swimming pools, spas, etc / If yes, describe below:

PROTECTION:

Smoke Alarms / In each unit (yes/no) / Hardwired / Battery / Central Station
Manual Fire Alarms (Yes/No) / Central Station (Yes/No)
Building Sprinklered (Yes/No) / All floors (Yes/No) / Cooking Area (Yes/No)
Storage or Stock Room (Yes/No) / In each room (Yes/No)
Check Type of sprinkler / Dry / Wet / Pipe Schedule / Hydraulic Design / Halon / CO2 / Foam
Wet Chemical / Dry Chemical / Other / Flow Alarm on sprinklers (Yes/No)
Written Evacuation Plan(Yes/No)
Do alarms ring into central security desk or nurses stations?
Is smoking allowed in facility (Yes/No) / If yes describe:

HIGH RISE

# Enclosed Stairwells: / # Hours Fire Rating / # Other Stairwells / # Fire Escapes
Smoke Detectors (Yes/No) / Heat Detectors (Yes/No) / Central Station Alarm (Yes/No)
Are openings in floors or fire walls protected by fire doors, fire dampers, etc (Yes/No)
Self Closing Doors (Yes/No) / Hallways / Stairways / Sleeping Units
# of Elevators / Heat Sensitive (Yes/No)
HVAC System / Equipped with Combustion Detector (Yes/No)
Programmed for Automated Shutdown (Yes/No) / Complete Exhaust(Yes/No)
Emergency Notification System (Yes/No) / If yes, describe:
Are there more than one means of egress from each floor (Yes/No) / Written Evacuation plan posted in each room (Yes/No)

COOKING FACILITIES

Operated by: / Applicant / Outside company / If outside company, does applicant have certificates of insurance on file (Yes/No)
Auto Extinguishing System (Yes/No) / UL 300 System (Yes/No)
Has required fuel shutoffs (Yes/No) / Covers all cooking and ventilation equipment (Yes/No)
Cooking Equipment #: / # Deep Fat Fryers / # Ranges / #Broilers / #Ovens
#Grilles / Other:
Is application compliance with both NFPA Standard #96 and UL 300 Standard (Yes/No)
Frequency of hood cleaning / Frequency of duct work cleaning
Professional hood and duct service firm used (Yes/No) / Name
Refrigeration maintenance agreement in place (Yes/No) / Name
Contract pest control services (Yes/No) / Any health code violations in last 3 years (yes/no)

AUTOMOBILE:

Does the applicant contract with outside company to transport residents (Yes/No)
If yes, answer a, b and c below
(a) Provide name of company
(b) Does applicant require proof of insurance
(c)What limit of insurance does applicant require
Does applicant have owned have Autos (Yes/No) / # of Autos
Does applicant transport residents (Yes/No)
Any vehicles with more than 8 passenger capacity (Yes/No) / If yes, what is maximum seating
Seating Capacity / VEH #1 / VEH #2 / VEH #3 / VEH #4 / VEH #5
Age of vehicles / VEH #1 / VEH #2 / VEH #3 / VEH #4 / VEH #5
Are there designated drivers for owned vehicles (Yes/No) / If no, explain
Does applicant review MVR’s for all drivers (yes/no) / How frequent are MVRs reviewed for all drivers?
Are employees with MVR violations allow to operate vehicles (yes/no) / Does applicant drug test drivers (yes/no)
Is operation radius of vehicles local only (Yes/No) / If no, explain
Is there a certified driver training course for new drivers (Yes/No)
Are signatures obtained from both driver and trainer after satisfactory completion of driver training course (Yes/No)
Are there written protocols for the loading and unloading wheel chairs (Yes/No).
If yes, please include copy with submission
Do volunteers transport residents (yes/no)
Is there a preventative maintenance program performed for vehicles (yes/no)
Do employees transport resident in their own vehicles (Yes/No)
If yes, answer a and b below
(a) Describe transportation activities
(b) Does applicant require employees to maintain minimum limits of insurance (yes/no) If yes, specific limits
Do volunteers operate any vehicles? (Yes/No)

Comments:

DECLARATION AND SIGNATURE

Authorized Entity Representative Designation

The person named herein is authorized and designated to give and receive any and all notices on behalf of the entity and all insureds from the entity or their authorized representative(s) concerning this insurance.

Named individual: ______Title or Position: ______

Attestation

The authorized signer of this application represents to the best of his/her knowledge and belief that the statements and information set forth herein are true and include all material information. The authorized signer also represents that any fact, circumstance or situation indicating the probability of a claim or legal action now known to any entity official or employee has been declared, and it is agreed by all concerned that the omission of such information shall exclude any such claim or action from coverage under the insurance being applied for. Signing of this application does not bind the Hanover Insurance Group, Inc. to offer, nor the authorized signer to accept insurance, but it is agreed this application and any attachments hereto shall be the basis of the insurance and will be incorporated by reference and made part of the policy should a policy be issued.

Signature of Authorized Entity Representative______

Date: ______

Hanover Insurance Group