Insurance for Addiction Treatment

General Information

Are you an Agent?

Yes

	Agency Name:
*	Contact Person:
*	Email Address:
	Phone Number:

Agency Address:

street

city

state

zip code

Mailing Address:

street

city

state

zip code

*	Policy Holder Name:
	Contact Person:
*	Phone Number:
*	Email Address:
	Website URL:
	FEIN Number:
	Association:

Is your facility Licensed?

Yes

Accredited / Certified by:

Do you own any other Business Ventures?

Yes

Business Type:

Corporation		Individual		Partnership		Not for Profit		LLC
Joint Venture		Trust

Date this business was established:
Proposed Effective Date of the Policy:

Claims and Lawsuits

Have you had any insurance claims or lawsuits in the past 3 years?

Yes

	Date of Claim	Description
Claim
Claim
Claim

Special Events

Are there any special events on premises or off site?

Yes

Special Event
Special Event
Special Event

Employees and Contractors

List any other employees or contractors who do work on your behalf:

	Name	Description of Duty
Employee/Contractor
Employee/Contractor
Employee/Contractor

Locations

Please select the number of locations you have:

Location 1

Building Address:

street

city

state

zip code

Construction Year:

ConstructionType:

Frame

Masonry

Square Footage:	sq. ft.
Number of Stories:
Number of Beds:

Check any updates within the last 15 years:

Roof

Plumbing

Electrical

What types of tenants do you allow?

Men

Women

Children

Do you own this building?

Yes

Do you operate the Sober Living program in this building?

Yes

Do you want coverage on the building?

Yes

Limit:

Deductible:

Do you want coverage on the contents?

Yes

Limit:

Deductible:

Do you want Loss of Rent Coverage

6 Months

1 Year

Monthly Rental Income:

Do you want coverage for hired and nonowned auto liability?

Yes

Do you provide tranportation for tenants?

Yes

Do you require all employees who transport tenant on your behalf to carry personal auto liability insurance?

Yes

Employee Driver Information for MVR review:

	Name	Date of Birth	License Number
Employee/Contractor
Employee/Contractor
Employee/Contractor

Check all that relate to this location:

Written Policies / Procedures	Drug / Alcohol Testing	Incident Reporting
Resident Manager	Overnight Guest	Pets
Simming Pool	Sauna	Excercise Equipment
Jacuzzi/Hottub

Check all Safety Measures:

	Automatic Sprinkler System		Fire Extinguishers		Smoke Alarms
	Burglar Alarm		Video Monitoring

List any Additional Interest:

(mortgagee, loss payee, other contracts requiring you to carry insurance)

Accreditation and/or Association
Accreditation and/or Association
Accreditation and/or Association

Additional Information

Location 2

Building Address:

Construction Year:

ConstructionType:

Frame

Masonry

Square Footage:	sq. ft.
Number of Stories:
Number of Beds:

Check any updates within the last 15 years:

Roof

Plumbing

Electrical

What types of tenants do you allow?

Men

Women

Children

Do you own this building?

Yes

Do you operate the Sober Living program in this building?

Yes

Do you want coverage on the building?

Yes

Limit:

Deductible:

Do you want coverage on the contents?

Yes

Limit:

Deductible:

Do you want Loss of Rent Coverage

6 Months

1 Year

Monthly Rental Income:

Do you want coverage for hired and nonowned auto liability?

Yes

Do you provide tranportation for tenants?

Yes

Do you require all employees who transport tenant on your behalf to carry personal auto liability insurance?

Yes

Employee Driver Information for MVR review:

	Name	Date of Birth	License Number
Employee/Contractor
Employee/Contractor
Employee/Contractor

Check all that relate to this location:

Written Policies and Procedures	Drug / Alcohol Testing	Incident Reporting
Resident Manager	Overnight Guest	Pets
Simming Pool	Sauna	Excercise Equipment
Jacuzzi/Hottub

Check all Safety Measures:

	Automatic Sprinkler System		Fire Extinguishers		Smoke Alarms
	Burglar Alarm		Video Monitoring

List any Additional Interest:

(mortgagee, loss payee, other contracts requiring you to carry insurance)

Accreditation and/or Association
Accreditation and/or Association
Accreditation and/or Association

Additional Information

Location 3

Building Address:

Construction Year:

ConstructionType:

Frame

Masonry

Square Footage:	sq. ft.
Number of Stories:
Number of Beds:

Check any updates within the last 15 years:

Roof

Plumbing

Electrical

What types of tenants do you allow?

Men

Women

Children

Do you own this building?

Yes

Do you operate the Sober Living program in this building?

Yes

Do you want coverage on the building?

Yes

Limit:

Deductible:

Do you want coverage on the contents?

Yes

Limit:

Deductible:

Do you want Loss of Rent Coverage

6 Months

1 Year

Monthly Rental Income:

Do you want coverage for hired and nonowned auto liability?

Yes

Do you provide tranportation for tenants?

Yes

Do you require all employees who transport tenant on your behalf to carry personal auto liability insurance?

Yes

Employee Driver Information for MVR review:

	Name	Date of Birth	License Number
Employee/Contractor
Employee/Contractor
Employee/Contractor

Check all that relate to this location:

Written Policies and Procedures	Drug / Alcohol Testing	Incident Reporting
Resident Manager	Overnight Guest	Pets
Simming Pool	Sauna	Excercise Equipment
Jacuzzi/Hottub

Check all Safety Measures:

	Automatic Sprinkler System		Fire Extinguishers		Smoke Alarms
	Burglar Alarm		Video Monitoring

List any Additional Interest:

(mortgagee, loss payee, other contracts requiring you to carry insurance)

Accreditation and/or Association
Accreditation and/or Association
Accreditation and/or Association

Additional Information

Location 4

Building Address:

Construction Year:

ConstructionType:

Frame

Masonry

Square Footage:	sq. ft.
Number of Stories:
Number of Beds:

Check any updates within the last 15 years:

Roof

Plumbing

Electrical

What types of tenants do you allow?

Men

Women

Children

Do you own this building?

Yes

Do you operate the Sober Living program in this building?

Yes

Do you want coverage on the building?

Yes

Limit:

Deductible:

Do you want coverage on the contents?

Yes

Limit:

Deductible:

Do you want Loss of Rent Coverage

6 Months

1 Year

Monthly Rental Income:

Do you want coverage for hired and nonowned auto liability?

Yes

Do you provide tranportation for tenants?

Yes

Do you require all employees who transport tenant on your behalf to carry personal auto liability insurance?

Yes

Employee Driver Information for MVR review:

	Name	Date of Birth	License Number
Employee/Contractor
Employee/Contractor
Employee/Contractor

Check all that relate to this location:

Written Policies and Procedures	Drug / Alcohol Testing	Incident Reporting
Resident Manager	Overnight Guest	Pets
Simming Pool	Sauna	Excercise Equipment
Jacuzzi/Hottub

Check all Safety Measures:

	Automatic Sprinkler System		Fire Extinguishers		Smoke Alarms
	Burglar Alarm		Video Monitoring

List any Additional Interest:

(mortgagee, loss payee, other contracts requiring you to carry insurance)

Accreditation and/or Association
Accreditation and/or Association
Accreditation and/or Association

Additional Information

Location 5

Building Address:

Construction Year:

ConstructionType:

Frame

Masonry

Square Footage:	sq. ft.
Number of Stories:
Number of Beds:

Check any updates within the last 15 years:

Roof

Plumbing

Electrical

What types of tenants do you allow?

Men

Women

Children

Do you own this building?

Yes

Do you operate the Sober Living program in this building?

Yes

Do you want coverage on the building?

Yes

Limit:

Deductible:

Do you want coverage on the contents?

Yes

Limit:

Deductible:

Do you want Loss of Rent Coverage

6 Months

1 Year

Monthly Rental Income:

Do you want coverage for hired and nonowned auto liability?

Yes

Do you provide tranportation for tenants?

Yes

Do you require all employees who transport tenant on your behalf to carry personal auto liability insurance?

Yes

Employee Driver Information for MVR review:

	Name	Date of Birth	License Number
Employee/Contractor
Employee/Contractor
Employee/Contractor

Check all that relate to this location:

Written Policies and Procedures	Drug / Alcohol Testing	Incident Reporting
Resident Manager	Overnight Guest	Pets
Simming Pool	Sauna	Excercise Equipment
Jacuzzi/Hottub

Check all Safety Measures:

	Automatic Sprinkler System		Fire Extinguishers		Smoke Alarms
	Burglar Alarm		Video Monitoring

List any Additional Interest:

(mortgagee, loss payee, other contracts requiring you to carry insurance)

Accreditation and/or Association
Accreditation and/or Association
Accreditation and/or Association

Additional Information

Location 6

Building Address:

Construction Year:

ConstructionType:

Frame

Masonry

Square Footage:	sq. ft.
Number of Stories:
Number of Beds:

Check any updates within the last 15 years:

Roof

Plumbing

Electrical

What types of tenants do you allow?

Men

Women

Children

Do you own this building?

Yes

Do you operate the Sober Living program in this building?

Yes

Do you want coverage on the building?

Yes

Limit:

Deductible:

Do you want coverage on the contents?

Yes

Limit:

Deductible:

Do you want Loss of Rent Coverage

6 Months

1 Year

Monthly Rental Income:

Do you want coverage for hired and nonowned auto liability?

Yes

Do you provide tranportation for tenants?

Yes

Do you require all employees who transport tenant on your behalf to carry personal auto liability insurance?

Yes

Employee Driver Information for MVR review:

	Name	Date of Birth	License Number
Employee/Contractor
Employee/Contractor
Employee/Contractor

Check all that relate to this location:

Written Policies and Procedures	Drug / Alcohol Testing	Incident Reporting
Resident Manager	Overnight Guest	Pets
Simming Pool	Sauna	Excercise Equipment
Jacuzzi/Hottub

Check all Safety Measures:

	Automatic Sprinkler System		Fire Extinguishers		Smoke Alarms
	Burglar Alarm		Video Monitoring

List any Additional Interest:

(mortgagee, loss payee, other contracts requiring you to carry insurance)

Accreditation and/or Association
Accreditation and/or Association
Accreditation and/or Association

Additional Information

Location 7

Building Address:

Construction Year:

ConstructionType:

Frame

Masonry

Square Footage:	sq. ft.
Number of Stories:
Number of Beds:

Check any updates within the last 15 years:

Roof

Plumbing

Electrical

What types of tenants do you allow?

Men

Women

Children

Do you own this building?

Yes

Do you operate the Sober Living program in this building?

Yes

Do you want coverage on the building?

Yes

Limit:

Deductible:

Do you want coverage on the contents?

Yes

Limit:

Deductible:

Do you want Loss of Rent Coverage

6 Months

1 Year

Monthly Rental Income:

Do you want coverage for hired and nonowned auto liability?

Yes

Do you provide tranportation for tenants?

Yes

Do you require all employees who transport tenant on your behalf to carry personal auto liability insurance?

Yes

Employee Driver Information for MVR review:

	Name	Date of Birth	License Number
Employee/Contractor
Employee/Contractor
Employee/Contractor

Check all that relate to this location:

Written Policies and Procedures	Drug / Alcohol Testing	Incident Reporting
Resident Manager	Overnight Guest	Pets
Simming Pool	Sauna	Excercise Equipment
Jacuzzi/Hottub

Check all Safety Measures:

	Automatic Sprinkler System		Fire Extinguishers		Smoke Alarms
	Burglar Alarm		Video Monitoring

List any Additional Interest:

(mortgagee, loss payee, other contracts requiring you to carry insurance)

Accreditation and/or Association
Accreditation and/or Association
Accreditation and/or Association

Additional Information

Location 8

Building Address:

Construction Year:

ConstructionType:

Frame

Masonry

Square Footage:	sq. ft.
Number of Stories:
Number of Beds:

Check any updates within the last 15 years:

Roof

Plumbing

Electrical

What types of tenants do you allow?

Men

Women

Children

Do you own this building?

Yes

Do you operate the Sober Living program in this building?

Yes

Do you want coverage on the building?

Yes

Limit:

Deductible:

Do you want coverage on the contents?

Yes

Limit:

Deductible:

Do you want Loss of Rent Coverage

6 Months

1 Year

Monthly Rental Income:

Do you want coverage for hired and nonowned auto liability?

Yes

Do you provide tranportation for tenants?

Yes

Do you require all employees who transport tenant on your behalf to carry personal auto liability insurance?

Yes

Employee Driver Information for MVR review:

	Name	Date of Birth	License Number
Employee/Contractor
Employee/Contractor
Employee/Contractor

Check all that relate to this location:

Written Policies and Procedures	Drug / Alcohol Testing	Incident Reporting
Resident Manager	Overnight Guest	Pets
Simming Pool	Sauna	Excercise Equipment
Jacuzzi/Hottub

Check all Safety Measures:

	Automatic Sprinkler System		Fire Extinguishers		Smoke Alarms
	Burglar Alarm		Video Monitoring

List any Additional Interest:

(mortgagee, loss payee, other contracts requiring you to carry insurance)

Accreditation and/or Association
Accreditation and/or Association
Accreditation and/or Association

Additional Information

Location 9

Building Address:

Construction Year:

ConstructionType:

Frame

Masonry

Square Footage:	sq. ft.
Number of Stories:
Number of Beds:

Check any updates within the last 15 years:

Roof

Plumbing

Electrical

What types of tenants do you allow?

Men

Women

Children

Do you own this building?

Yes

Do you operate the Sober Living program in this building?

Yes

Do you want coverage on the building?

Yes

Limit:

Deductible:

Do you want coverage on the contents?

Yes

Limit:

Deductible:

Do you want Loss of Rent Coverage

6 Months

1 Year

Monthly Rental Income:

Do you want coverage for hired and nonowned auto liability?

Yes

Do you provide tranportation for tenants?

Yes

Do you require all employees who transport tenant on your behalf to carry personal auto liability insurance?

Yes

Employee Driver Information for MVR review:

	Name	Date of Birth	License Number
Employee/Contractor
Employee/Contractor
Employee/Contractor

Check all that relate to this location:

Written Policies and Procedures	Drug / Alcohol Testing	Incident Reporting
Resident Manager	Overnight Guest	Pets
Simming Pool	Sauna	Excercise Equipment
Jacuzzi/Hottub

Check all Safety Measures:

	Automatic Sprinkler System		Fire Extinguishers		Smoke Alarms
	Burglar Alarm		Video Monitoring

List any Additional Interest:

(mortgagee, loss payee, other contracts requiring you to carry insurance)

Accreditation and/or Association
Accreditation and/or Association
Accreditation and/or Association

Additional Information

Location 10

Building Address:

Construction Year:

ConstructionType:

Frame

Masonry

Square Footage:	sq. ft.
Number of Stories:
Number of Beds:

Check any updates within the last 15 years:

Roof

Plumbing

Electrical

What types of tenants do you allow?

Men

Women

Children

Do you own this building?

Yes

Do you operate the Sober Living program in this building?

Yes

Do you want coverage on the building?

Yes

Limit:

Deductible:

Do you want coverage on the contents?

Yes

Limit:

Deductible:

Do you want Loss of Rent Coverage

6 Months

1 Year

Monthly Rental Income:

Do you want coverage for hired and nonowned auto liability?

Yes

Do you provide tranportation for tenants?

Yes

Do you require all employees who transport tenant on your behalf to carry personal auto liability insurance?

Yes

Employee Driver Information for MVR review:

	Name	Date of Birth	License Number
Employee/Contractor
Employee/Contractor
Employee/Contractor

Check all that relate to this location:

Written Policies and Procedures	Drug / Alcohol Testing	Incident Reporting
Resident Manager	Overnight Guest	Pets
Simming Pool	Sauna	Excercise Equipment
Jacuzzi/Hottub

Check all Safety Measures:

	Automatic Sprinkler System		Fire Extinguishers		Smoke Alarms
	Burglar Alarm		Video Monitoring

List any Additional Interest:

(mortgagee, loss payee, other contracts requiring you to carry insurance)

Accreditation and/or Association
Accreditation and/or Association
Accreditation and/or Association

Additional Information