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    Dallas, Texas 75206
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    • How To Prevent a Holiday Season Home Burglary

      How To Prevent a Holiday Season Home Burglary

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Adult Foster Care Insurance Quote

Adult Foster Care Insurance QuoteEric Graves2024-06-25T21:42:37-05:00

Step 1 of 11

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Contact Name
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Mailing Address
Same as Physical Address?
Physical Address
Organization Type?

Current Insurance Information

Do you currently have insurance?
MM slash DD slash YYYY
Have you had any claims in the last 5 years?
Does your current insurance program include?
MM slash DD slash YYYY
Is it?
MM slash DD slash YYYY

General Information

Are all facilities licensed through the state?
Has your license ever been suspended, revoked, or placed under conditional status OR claims of negligence?
MM slash DD slash YYYY
Any violations noted?
Are counseling services offered for any of the following?
Check all that apply.
Do you operate any other locations not included on this application?
Is insurance in place at these other locations?

Property Details

Is this location? Street Address Square Footage Actions
     
There are no Properties.

Maximum number of properties reached.

Facility Information

Occupancy: Number of Beds by Resident Type: Annual Residents by Age: Actions
     
There are no Facilities.

Maximum number of facilities reached.

Resident unauthorized leave prevention?
Check all that apply.
Does a physician screen clients prior to admission?
Are residents responsible for their own basic personal care?
Example: Bathing, dressing, eating, restroom aide.
Do you allow physical restraint?
Resident Rooms
Inspection Freq.
By Who
How often?
Is there a written plan for supervising staff when interacting with clients on and off premises?
Are security cameras monitoring operations and residents?
Are resident's door ever locked from the outside?
Are residents allowed to cook their own meals?
How?
Is there a pool?
Who uses the pool?
Check all that apply.
Is the pool fenced with a self-locking gate?
Is there a diving board?
Is there trained staff on water safety?

Management Practices

Do you have sign in/out procedures for?
Check all that apply.
What is your client to staff ratio?
Day
Night

Abuse Prevention

Do you run criminal background checks, including sex/child abuse related crimes, before an employment offer?
This includes employees and volunteers.
Do you have a crisis plan for dealing with an incident of abuse?
Is there formal training on child/sexual abuse?
Are closed door one-on-one meetings prohibited?
Have any incidents resulted in an allegation of sexual abuse?
Was the case taken to trial?

Human Resources

Type: Employee - FT Employee - PT Contracted - PT Contracted - PT Annual Payroll Actions
           
There are no Staff.

Maximum number of staff reached.

Aprox. how many FT and PT employees two years ago?
Full Time
Part Time
Employee changes over the past twelve (12) months?
Left
Let Go
Laid Off
Demoted
Anticipated Employee changes over the past twelve (12) months?
Reductions
Layoffs
Demotions
Do you have written job descriptions for each employee?
Is drug testing conducted?
Do you train and require all staff to report incidents, in writing, and do you investigate each incident?

Workers Compensation

Which of the following contracted services are utilized?
Are there written agreements with those contractors?
Do you collect certificates of insurance from your contractors?

Financials

Annual Revenue:
Current Fiscal Year
Previous Fiscal Year
Annual Budget:
Current Fiscal Year
Previous Fiscal Year
Total Assets:
Current Fiscal Year
Previous Fiscal Year
Net Assets / Fund Balance:
Current Fiscal Year
Previous Fiscal Year
Do you offer a retirement plan?
Plan Details
Name
Established
Assets
Type
Participants
Administrator
Do you file a Form 5500 each year?
Request a copy of most recent filing.
Is your organization more than 25% owned by private equity?
Any mergers or operations under another name in the last five (5) years?

Vehicles and Transportation

Year Make Model Actions
     
There are no Vehicles.

Maximum number of vehicles reached.

Are all vehicles registered to the organization?
Do employees or volunteers use their personal vehicles for business?
How many use their own vehicles for business use?
Full Time - Driving over 20 hours per week Part Time - Driving up to 20 hours per week
Full Time
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Volunteers
Do you run MVRs on employees?
Do you require employees and volunteers to carry and show evidence of personal auto insurance?
Do you provide transportation services?
Do vehicles equipped for wheelchairs have tie-down belts?
Do you have a formal maintenance and safety training program in place?
Does Applicant utilize GPS fleet telematics devices?
Fleet Telematics Utilized

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Office Address

5740 Prospect Avenue Suite 2000
Dallas, Texas 75206
Phone: 214-699-7484
Fax: 972-521-9229

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Dallas, TX 75205

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If your application contains purposefully misleading, absent, or inaccurate information, you could be charged with fraud. Your insurance carrier could potentially void your policy, or you could face civil or criminal charges or penalties.

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