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

We look forward to hearing from you. If you need any assistance, please contact Jon Klein at jklein@mahoneygroup.com or Steve Perkins at sperkins@mahoneygroup.com. They would be happy to help you complete this questionnaire.

If you'd like, please print and mail this information to:

     Jonathan Klein, CPCU
     The Mahoney Group
     3719 N. Campbell Ave.
     Tucson, AZ 85719
     520-795-8511 Phone
     520-795-8542 Fax


    
 
 
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