Affinity Insurance Agency, Inc.
Elder Care Indication Form
LIABILITY INFORMATION
Name:
Contact Person:
Address:
Email:
City:
State:
Zip Code:
Phone:
Fax:
Effective Date:
Retro Date:
Current Carrier:
Current Coverage Form:
Claims Made:
Occurrence:
Staffing per shift:
Account Type: Check the one below that applies to your facility.
Independent Living:
Assisted Living
Skilled Nursing Home
Continuing Care Retirement Center
Group Home
Home Health Care
Allied Health Care – Other
Social Services - Other
Total Beds:
# of Employees:
# of Part Time Employees:
Expiring GL/PL Premium:
GL/PL Limits:
5-Year Loss Ratio:
Gross Revenue:
Exposure States:
Comments/Description:
Phone: 770-974-5502
Fax: 770-974-5359
Mail: mklocke@profliability.com
3950 Cobb Parkway, Suite 707
Acworth, GA 30101