Fill out the questionnaire and submit it here.

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