Please note, when completing the application, you will need your entity's financials.
Agents and Brokers, please click here to submit an online application for your client.

NON-PROFIT HOMES AND SERVICES FOR THE AGING
DIRECTORS' & OFFICERS' LIABILITY INSURANCE
This is an application for a claims-made policy which, subject to its provisions, applies only to and Claim first made against the Insureds during the Policy Period. No coverage exists for Claims first made after the end of the Policy Period unless, and to the extent, the Extended Reporting Period applies.

  Section I
  Applicant Information
Applicant to be named in Item 1
of the Declarations (Named Entity):
Address:  
City:       State:       Zip Code:  
Telephone:   -  Fax:
Email:   
1. Is the Applicant currently a Non Profit entity under the IRS code 501(c)?............................       Yes No
2. Years in business: a. less than 3 b. 3-5 c. 6-10 d. more than 10
3. Accreditations: CCAC JCAHO None Other:
4. Is coverage requested for any For Profit subsidaries? If yes, please provide a list along with
    Nature of Operations for each (coverage is not necessarily guaranteed)...............................		 Yes No

   Section II
  Facility Type
Skilled Nursing Facility Continuing Care Retirement Community
Assisted Living Senior Housing/Independent Living Facility
Services For the Elderly
(e.g referral services; adult day care) 		Other:
Number of Beds: 0 - 50 51 - 100 101 - 250 251 - 500
  501 - 750 751 - 1000 1001 - 2500 2500+
           

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