Does applicant allow for an outside management company to supervise, operate or manage the facility.^* Yes No

Does applicant allow vendors or independent contractors to enter the facility who do not have insurance coverage equal to or greater than the amount of coverage maintained by the Facility?^* Yes No

Has applicant had any deficiencies or identified by a regulator not resolved to the satisfaction of that regulator?^* Yes No

Does applicant operate the licensed facility “outside” of State guidelines set forth by State Licensing Requirements?^* Yes No

Has the applicant, its owners, management, or shareholders ever been convicted for an act committed in violation of any law or ordinance, other than a misdemeanor? ^* Yes No

Does applicant accept any of the following type of prohibited residents:^* Yes No

Is the applicant aware of any written or oral allegations of wrongdoing, with or without merit, which have not previously been submitted to, and accepted by, an existing or prior insurer? ^* Yes No

Is the applicant aware of any event, occurrence, or matter, irrespective of merit, that they will file a claim on the insurance coverage sought through this application? ^* Yes No

In the past five years, has the applicant received any written correspondence (including email) from an attorney or law firm representing a resident or former resident? ^* Yes No

Does the applicant understand and agree that any matter based upon, arising out of, or related to, in whole or in part, circumstances or allegations disclosed or not disclosed in response to the prior three questions will be excluded from coverage under any insurance sought though this application? ^* Yes No

Is the applicant currently either an “Active” or “Pending” Licensed Residential Care Facility through the State?^* Yes No

Does the applicant have a written admissions agreement executed by each resident? ^* Yes No

Does the applicant perform an assessment for new residents, including evaluation of skin breakdowns, history of injuries including falls, assistance with daily living activities, wandering risk and current medications?^* Yes No

Does the applicant have a system to ensure timely reassessments and identify when a resident needs to be transferred to another level of care?^* Yes No

Does the applicant perform background checks as part of pre-employment screening? ^* Yes No

Does applicant store and lock medications?^* Yes No

Does applicant document medication distribution on a chart after each time medication is distributed?^* Yes No

Does applicant stay within the allowable number of each type of residents it is licensed to accept? (i.e. hospice, dementia, bed-ridden, non-am)^* Yes No

Does applicant have protocols in place to prevent residents from abuse and wandering?^* Yes No

Does applicant confirm there have been no elopements within the last 12 months? ^* Yes No

Does applicant have procedures properly in place to allow for memory care residents? ^* Yes No

Does applicant have auditory alarms on all exits? ^* Yes No

If facility has a waterfront, pool, or hot tub, is it gated and locked and are residents prohibited from access and use? ^* Yes No

When an incident such as a fall, injury, or any harm to a resident occurs, does the applicant log the incidents on an incident report,send notice to the family and/or doctor, and put notice into the file of the resident within 3 days of an incident? ^* Yes No

Does applicant confirm they are continuing to follow state and CDC guidelines related to COVID-19? ^* Yes No