Contact Name

First Last

Position

Email

Phone

Business Legal Name

DBA?

Mailing Address

Street Address Address Line 2 City State ZIP Code

Same as Physical Address?

Yes

No

Physical Address

Street Address Address Line 2 City State ZIP Code

Organization Type?

Corp.

LLC

Non-Profit

Year Founded

Years Under Same Mngt?

Website

FEIN #

SIC #

Property Details

Untitled

Is this location?	Street Address	Square Footage	Actions

There are no Properties.

Facility Information

Facilities

Occupancy:	Number of Beds by Resident Type:	Annual Residents by Age:	Actions

There are no Facilities.

Resident unauthorized leave prevention?

Check all that apply.

Exit doors locked

Wristband sensor with alarm

Exit doors alarmed

How often are residents checked to ensure they're at the facility?

How are residents separated?

Does a physician screen clients prior to admission?

Yes

No

Are residents responsible for their own basic personal care?

Example: Bathing, dressing, eating, restroom aide.

Yes

No

Do you allow physical restraint?

Yes

No

Which non-violent crisis intervention protocol is used?

Which method of de-escalation is used?

How do you provide for resident privacy and security?

What procedures are in place for clients allowed to leave without supervision?

On average, how many visits per month are made by a caseworker?

Resident Rooms

Inspection Freq.

By Who

How often?

Is there a written plan for supervising staff when interacting with clients on and off premises?

Yes

No

Are security cameras monitoring operations and residents?

Yes

No

Are resident's door ever locked from the outside?

Yes

No

Are residents allowed to cook their own meals?

Yes

No

How?

Private

Common cooking area

Is there a pool?

Yes

No

Who uses the pool?

Check all that apply.

Visitors

Staff

Clients/Residents

Is the pool fenced with a self-locking gate?

Yes

No

Height of the fence?

Is there a diving board?

Yes

No

Is there trained staff on water safety?

Yes

No

Management Practices

Do you have sign in/out procedures for?

Check all that apply.

Staff

Clients/Residents

Visitors/Public

What precautions are utilized to prevent unauthorized access?

What is your client to staff ratio?

Day

Night

Human Resources

Staff Type

Type:	Employee - FT	Employee - PT	Contracted - PT	Contracted - PT	Annual Payroll	Actions

There are no Staff.

Aprox. how many FT and PT employees two years ago?

Full Time

Part Time

Staff turnover ratio for the last twelve (12) months?

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?

Yes

No

Is drug testing conducted?

Yes

No

Do you train and require all staff to report incidents, in writing, and do you investigate each incident?

Yes

No

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?

Yes

No

Plan Details

Name

Established

Assets

Type

Participants

Administrator

Do you file a Form 5500 each year?

Request a copy of most recent filing.

Yes

No

Why not?

Is your organization more than 25% owned by private equity?

Yes

No

Name of the firm?

Any mergers or operations under another name in the last five (5) years?

Yes

No

Please explain

Vehicles and Transportation

Vehicles

Year	Make	Model	Actions

There are no Vehicles.

Are all vehicles registered to the organization?

Yes

No

Please Explain

Do employees or volunteers use their personal vehicles for business?

Yes

No

Describe Use

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

Part Time

Volunteers

Do you run MVRs on employees?

Yes

No

How often?

Do you require employees and volunteers to carry and show evidence of personal auto insurance?

Yes

No

Do you provide transportation services?

Yes

No

Do vehicles equipped for wheelchairs have tie-down belts?

Yes

No

Do you have a formal maintenance and safety training program in place?

Yes

No

Please describe any ongoing training provided to drivers?

Does Applicant utilize GPS fleet telematics devices?

Yes

No

Fleet Telematics Utilized

Plug In

Hard Wired

Mobile Phone

Other

Other Telematics

Percentage of fleet provided with telematics devices

Personal Insurance

Business Insurance

Industries We Insure

Personal Insurance

Business Insurance

Industries We Insure

Personal

Account Review

Business

Account Review

For Clients

Adult Foster Care Insurance Quote

Current Insurance Information