Applications

Applications

​Broker Appointment Questionnaire

Submission Requirements

  • Main & Facility supplemental applications
  • Five(5) years of currently valued loss runs with details on all claims over $100k
  • All state survey reports for the last 15 months (including corrective action plans)
  • All substantiated complaint surveys for the last 15 months (including corrective action plans)
  • Financials
  • Licenses for Each Location
  • Current Policy Dec Page

  • For SNF’s: Facility Quality Measures/Indicator Reports not older than 90 days
  • For SNF’s: Current CMS Forms 671 Facility Staffing & 672 Resident Census

Supplemental Applications