sober living homes application - nsm insurance€¦ · microsoft word - sober living app - working...

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Applicant NLocation AddressMailing AddressContact Person:Phone NumberE-mail AddressWebsiteFEIN:Description of Operations:

10. Other Business Ventures:11. Corporation12. Date the business was established:13. Proposed Eff. Date:14. Is your facility:15. Accreditations and/or Association memberships:16. Total number of beds:17. Men☐18. What is your approximate monthly rental income?19. Current liability insurance carrier?20. Have you had any insur

If Yes, please provide the date, explanation and outcome:

21. Any additional interests in this insurance (mortgagee, loss payee, or

22. Do you have written policies and procedures for tenants?23. Do you administer drug or alcohol testing of tenants?24. Do you have incident reporting procedures?

If Yes, is a written record kept?25. Do you allow guests/visitors to stay overnight?26. Do you allow residents to keep pets on27. Is there a:28. Any special events on premises or off site?

If Yes, please describe:29. Is there a resident manager on premises?30. List any other employees or contractors

31. Do you currently have Worker’s Compensation insurance?32. Do you currently have Commercial Auto insurance? (If Yes, appl. &33. Do you provide transportation

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Applicant Name:Location Address:Mailing Address:Contact Person:Phone Number:

mail Address:Website:

Description of Operations:Other Business Ventures:Corporation☐ IndividualDate the business was established:Proposed Eff. Date:Is your facility: LicensedAccreditations and/or Association memberships:Total number of beds:

Women☐What is your approximate monthly rental income?Current liability insurance carrier?Have you had any insur

, please provide the date, explanation and outcome:

Any additional interests in this insurance (mortgagee, loss payee, or

Do you have written policies and procedures for tenants?Do you administer drug or alcohol testing of tenants?Do you have incident reporting procedures?

, is a written record kept?Do you allow guests/visitors to stay overnight?Do you allow residents to keep pets onIs there a: Swimming PoolAny special events on premises or off site?

, please describe:Is there a resident manager on premises?List any other employees or contractors

Do you currently have Worker’s Compensation insurance?Do you currently have Commercial Auto insurance? (If Yes, appl. &Do you provide transportation


Sober Living Homes Application

Description of Operations:Other Business Ventures:

Individual☐Date the business was established:Proposed Eff. Date:

Licensed☐Accreditations and/or Association memberships:Total number of beds:

☐ Men & WomenWhat is your approximate monthly rental income?Current liability insurance carrier?Have you had any insurance claims or lawsuits in the past 3 years?

, please provide the date, explanation and outcome:



, is a written record kept?Do you allow guests/visitors to stay overnight?Do you allow residents to keep pets on

Swimming Pool☐Any special events on premises or off site?

, please describe:Is there a resident manager on premises?List any other employees or contractors

Do you currently have Worker’s Compensation insurance?Do you currently have Commercial Auto insurance? (If Yes, appl. &Do you provide transportation



PartnershipDate the business was established:

Certified☐Accreditations and/or Association memberships:

Men & Women☐What is your approximate monthly rental income?Current liability insurance carrier?

ance claims or lawsuits in the past 3 years?, please provide the date, explanation and outcome:



, is a written record kept?Do you allow guests/visitors to stay overnight?Do you allow residents to keep pets on the premises?

Jacuzzi/Hot TubAny special events on premises or off site?

Is there a resident manager on premises?List any other employees or contractors who do work on your behalf:

Do you currently have Worker’s Compensation insurance?Do you currently have Commercial Auto insurance? (If Yes, appl. &Do you provide transportation for tenants?


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Partnership☐ LLC☐

☐ by:Accreditations and/or Association memberships:

☐ Women & ChildrenWhat is your approximate monthly rental income?




Do you allow guests/visitors to stay overnight?the premises?

Jacuzzi/Hot TubAny special events on premises or off site?

Is there a resident manager on premises?who do work on your behalf:

Do you currently have Worker’s Compensation insurance?Do you currently have Commercial Auto insurance? (If Yes, appl. &

for tenants?

3


☐ Joint Venture

Proposed Exp. Date:

Approx. sq. fWomen & Children


Any additional interests in this insurance (mortgagee, loss payee, or contracts requiring you to carry insurance?

Do you have written policies and procedures for tenants?Do you administer drug or alcohol testing of tenants?

the premises?Jacuzzi/Hot Tub☐ Sauna

who do work on your behalf:

Do you currently have Worker’s Compensation insurance? (If Yes, appl. & loss runs)Do you currently have Commercial Auto insurance? (If Yes, appl. &

555 North Lane, Suite 6060

Send to: atp


Joint Venture☐

Proposed Exp. Date:

Approx. sq. footage:Women & Children☐

Annual Premium?ance claims or lawsuits in the past 3 years?

contracts requiring you to carry insurance?

Sauna☐

who do work on your behalf:

(If Yes, appl. & loss runs)Do you currently have Commercial Auto insurance? (If Yes, appl. & loss runs)


Conshohocken, Pa 19428

Phone: (800) 970

FAX: (610) 941

Send to: [email protected]


Trust☐ Not For Profit

Proposed Exp. Date:

ootage:

ual Premium?


Exercise Equipment

(If Yes, appl. & loss runs)loss runs)



Phone: (800) 970-9778

FAX: (610) 941-9889

[email protected]

Not For Profit

ual Premium?Yes☐ No


Yes☐ NoYes☐ NoYes☐ NoYes☐ NoYes☐ NoYes☐ No

Exercise EquipmentYes☐ No

Yes☐ No

(If Yes, appl. & loss runs) Yes☐ NoYes☐ NoYes☐ No



9778

9889

[email protected]

Not For Profit☐

No☐

contracts requiring you to carry insurance?)

No☐ No☐No☐No☐No☐No☐

Exercise Equipment☐ No☐

No☐

No☐No☐ No☐

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34. Do you require all employees who transport tenants on your behalf to carry minimumpersonal auto liability insurance limit of $100,000? Yes☐ No☐

35. Employee driver information for MVR review:Name: DL #: DOB:

36. What year was your building constructed?37. Updates in last 15 years: Roof☐ Plumbing☐ Electrical☐ 38. Construction type: Wood Frame☐ Masonry/Concrete Block☐ 39. Number of stories:40. Automatic Sprinkler System☐ Fire Extinguishers☐ Smoke Alarms☐ Burglar Alarm☐ Video☐ 41. Are any protective systems connected to offsite monitoring company? Yes☐ No☐ 42. Current property insurance carrier? Annual Premium?43. Have you had any property insurance claims in the past 3 years? Yes☐ No☐

If Yes, please provide date and description of loss:

44. Building limit of insurance (full replacement cost): $45. Business personal property limit of insurance (full replacement cost): $46. Deductible: $500☐ $1,000☐ $2,500☐ $5,000☐ 47. Public Fire Protection Class:48. Loss of Rents limit of insurance: $ Limit shown for: 6 Months☐ 1 Year☐

Additional coverage information/notes:

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FRAUD NOTICE STATEMENTS

ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES ANAPPLICATION FOR INSURANCE CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS, FOR THE PURPOSE OFMISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT, WHICH ISA CRIME AND SUBJECTS THAT PERSON TO CRIMINAL AND CIVIL PENALTIES (IN OREGON, THE AFOREMENTIONED ACTIONS MAYCONSTITUTE A FRAUDULENT INSURANCE ACT WHICH MAY BE A CRIME AND MAY SUBJECT THAT PERSON TO PENALTIES). (INNEW YORK, THE CIVIL PENALTY IS NOT TO EXCEED FIVE THOUSAND DOLLARS ($5,000) AND THE STATED VALUE OF THE CLAIMFOR EACH SUCH VIOLATION).(NOT APPLICABLE IN AL, AR, AZ, CO, DC, FL, KS, LA, ME, MD, MN, NM, OK, RI, TN, VA, VT, WA AND WV).

APPLICABLE IN AL, AR, AZ, DC, LA, MD, NM, RI AND WV: ANY PERSON WHO KNOWINGLY (OR WILLFULLY IN MD) PRESENTS AFALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR WHO KNOWINGLY (OR WILLFULLY IN MD) PRESENTSFALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES ORCONFINEMENT IN PRISON.

APPLICABLE IN COLORADO: IT IS UNLAWFUL TO KNOWINGLY PROVIDE FALSE, INCOMPLETE, OR MISLEADING FACTS ORINFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THECOMPANY. PENALTIES MAY INCLUDE IMPRISONMENT, FINES, AND DENIAL OF INSURANCE AND CIVIL DAMAGES. ANYINSURANCE COMPANY OR AGENT OF AN INSURANCE COMPANY WHO KNOWINGLY PROVIDES FALSE, INCOMPLETE, ORMISLEADING FACTS OR INFORMATION TO A POLICYHOLDER OR CLAIMANT FOR THE PURPOSE OF DEFRAUDING ORATTEMPTING TO DEFRAUD THE POLICYHOLDER OR CLAIMANT WITH REGARD TO A SETTLEMENT ORAWARD PAYABLE FROMINSURANCE PROCEEDS SHALL BE REPORTED TO THE COLORADO DIVISION OF INSURANCE WITHIN THE DEPARTMENT OFREGULATORY AGENCIES.

APPLICABLE IN FLORIDA AND OKLAHOMA: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, ORDECIEVE ANY INSURER FILES A STATEMENT OF CLAIM OR AN APPLICATION CONTAINING ANY FALSE, INCOMPLETE, ORMISLEADING INFORMATION IF GUILTY OF A FELONY (IN FL, A PERSON IS GUILTY OF A FELONY OF THE THIRD DEGREE).

APPLICABLE IN KANSAS: ANY PERSON WHO, KNOWINGLY AND WITH INTENT TO DEFRAUD, PRESENTS, CAUSES TO BEPRESENTED OR PREPARES WITH KNOWLEDGE OR BELIEF THAT IT WILL BE PRESENTED TO OR BY AN INSURER, PERPORTEDINSURER, BROKER OR ANY AGENT THEREOF, ANY WRITTEN STATEMENT AS PART OF, OR IN SUPPORT OF, AN APPLICATION FORTHE ISSUANCE OF, OR THE RATING OF AN INSURANCE POLICY FOR PERSONAL OR COMMERCIAL INSURANCE, OR A CLAIM FORPAYMENT OR OTHER BENEFIT PURSUANT TO AN INSURANCE POLICY FOR COMMERCIAL OR PERSONAL INSURANCE WHICHSUCH PERSON KNOWS TO CONTAIN MATERIALLY FALSE INFORMATIONCONCERNING ANY FACT MATERIAL THERETO; ORCONCEALS, FOR THE PURPOSE OFMISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO COMMITS AFRAUDULENT INSURANCE ACT.

APPLICABLE IN MAINE, TENNESSEE, VIRGINIA AND WASHINGTON: IT IS A CRIME TO KNOWINGLY PROVIDE FALSE,INCOMPLETE OR MISLEADING INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THECOMPANY. PENBALTIES MAY INCLUDE IMPRISONMENT, FINES OR A DENIAL OF INSURANCE BENEFITS.

THE UNDERSIGNED STATES THAT HE/SHE IS AN AUTHORIZED REPRESENTATIVE OF THE APPLICANT AND DECLARES TOTHE BEST OF HIS/HER KNOWLEDGE AND BELIEF AND AFTER REASONABLE INQUIRY, THAT THE STATEMENTS SET FORTHIN THIS APPLICATION (AND ANY ATTACHMENTS SUBMITTED WITH THIS APPLICATION) ARE TRUE AND COMPLETE.

THE SIGNING OF THIS APPLICATION DOES NOT BIND THE COMPANY TO OFFER, OR THE APPLICANT TO PURCHASE THEPOLICY.

APPLICANT NAME (PLEASE PRINT/TYPE) TITLE

APPLICANT’S SIGNATURE DATE

sober living homes application - nsm insurance€¦ · microsoft word - sober living app - working...

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