Affinity Insurance Agency, Inc.
Premium Estimate Elder Care
TO: Affinity Insurance Agency
3950 Cobb Parkway, Suite 707
Acworth, GA 30101
Tel. 770-974-5502
Fax 770-974-5359
Name:
Contact Person:
Phone:
Email:
Effective Date:
Current Carrier:
Address:
City:
State:
Zip:
Fax:
Website:
Retro Date:
Current Coverage Form:
Claims Made:
Occurrence:
# of Beds:
# of Homes:
Account Type: Circle the one below that applies to your facility.
Independent Living:
Group Home - PCH:
Assisted Living:
Home Health Care:
Skilled Nursing Home:
Allied Health Care – Other:
Continuing Care Retirement Center:
Social Services - Other:
Total Number of staff:
How many are CNA's:
Staffing
per shift
:
Expiring GL/PL Premium:
GL/PL Limits:
5-Year Loss Ratio:
Gross Revenue:
Have there been any developments?
(Clients left the premises)
Does your facility have smoke detectors, fire alarms or sprinklers?
Are the exits alarmed?
Exposure States:
Does the facility accept Alzheimer's or dementia clients?
Does the facility accept developmentally disabled clients?
Comments:
3950 Cobb Parkway, Suite 707 Acworth, GA 30101
Tele. (770) 974-5502 * Fax (770) 974-5359
June 2008
