The Mahoney Group - Quotes: Property & Liability Questionnaire


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Location: Home >> Quotes >> Property & Liability Questionnaire

Property & Liability Questionnaire

Please fill out the information below and we will send you a quote by e-mail.
We suggest you take the information you'll need from your current policy.

Contact Information

Company Name:
Type of organization:	(Corporation, Partnership, Etc.)
Street Address:
Address (cont.):
City:
State/Province:
Zip/Postal Code:

Work Phone:
Home Phone:
How did you hear about us? :
E-mail:
Method of contact?
Best time to call:

General Information

Date Business Established:
Present Insurance Company:
Current Policy Expiration Date:	(MM/DD/YYYY)
List Any Claims in the Past 3 Years with Amounts Paid or Reserved (if known): (If none, state none)
Licenses Held with State:
Number of Residents:

Resident Information

	# of Residents	Ambulatory	Non-Ambulatory
Alzheimer's
Senile/Dementia
Assisted Living
Independent Living
Residents Under Age 65

What Medications are Administered and In What Forms?

Staff
	RN's:
	LPN's:
	Other Caregivers:
	All Others:

Are There Any Services Provided by Staff or Independent Contractors, such as Beauticians, Physicians?	Yes No
Do They Carry Their Own Insurance and Provide You with a Certificate of Insurance?	Yes No

Please answer the Following Questions About Your Building
	Construction (frame, masonry, etc.):
	Number of Stories:
	Year Built:
	Sprinklers?	Yes No
	Smoke Detectors in Every Room and Hallway?	Yes No
	Fire Alarm? (If yes, local or central station)	Yes No
	Designated Smoking Areas?	Yes No
	Distance to Nearest Fire Station:
	Do Bathrooms and Hallways Have Handrails?	Yes No
	Are Bathtubs and Showers Equipped with Non-Skid Surfaces?	Yes No
	Is There an Emergency Evacuation Plan?	Yes No
	Swimming Pool? If yes, what protection and staffing is available?	Yes No

Vehicle Information
	Do You Own or Lease Any Vehicles?	Yes No
	If yes, please provide the following:

	Year:
	Make:
	Model:
	Cost New: $
	% of Use:	%

Insurance Information
	Have You Ever Had Your Insurance Cancelled, Non-Renewed or Declined?	Yes No

You may print this form and mail or fax it to:

     The Mahoney Group
     1119 E Cottonwood Ln
     Casa Grande, AZ 85122
     520-836-6681 Fax

www.MahoneyGroup.com

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