quickquote testing - PCALIC - Personal Care and Assisted Living Insurance Center

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First Name:
Last Name:
Name on License:
Phone:
Email:
State:
Number of Licensed Beds:
Effective Date Requested:	Open the calendar
Limit of Liability Requestingddd:
Is there a swimming pool on the premises?	Yes No
Is the pool fenced with a locked gate?	Yes No
Does the pool have an alarm in it?	Yes No
Are residents permitted to use the pool?	Yes No
Do you accept residents under age 18?	Yes No
Do you have alarms on all exterior doors?	Yes No
Is your facility inspected by the fire department annually?	Yes No
Do you utilize a Negotiated Risk Agreement with residents?	Yes No
Do you record medication and medical records on a computer system?	Yes No
Do bedridden and wheelchair dependent residents exceed 50% of your residents?	Yes No


Indication Number:
Premium:
Capital Contribution:
Underwriting Fees:

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- Annie Fehnel

Morning Star Manor, Inc

- Ana Walker

Walker’s Group Assisted Living

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