HANOVER INSURANCE GROUP ASSISTED LIVING AND SKILLED NURSING LOCATION

Applicant’s Name

Agency Name

Mailing Address

Expiration Date

Location

Describe Facility Type (Adult Assisted Living, Intermediate Care, Skilled Nursing, Continuing Care, Other)

# Years in Business

# Years under current management

Is the facility profit or not for profit

% Rooms that are private pay

# of Rooms

Avg Room Rate (Monthly rate for assisted living, daily rate for nursing)

Average Occupancy %

# of continuous years application has maintained a profit

Is there a manager on premises/duty 24 hours (Yes/No)

If no, when

Is there a preventative maintenance program (Yes/No) If yes, check type below

Scheduled Maintenance for all key building systems

Deferred Maintenance for all key building systems

Strategy of no Maintenance prior to repair

Are there kitchenettes in guest rooms (Yes/No)

If yes, describe

Are there any amenities such as swimming pools, spas, etc

If yes, describe below:

Smoke Alarms

In each unit (yes/no)

Hardwired

Battery

Central Station

Manual Fire Alarms (Yes/No)

Central Station (Yes/No)

Building Sprinklered (Yes/No)

All floors (Yes/No)

Cooking Area (Yes/No)

Storage or Stock Room (Yes/No)

In each room (Yes/No)

Check Type of sprinkler

Dry

Wet

Pipe Schedule

Hydraulic Design

Halon

CO2

Foam

Wet Chemical

Dry Chemical

Other

Flow Alarm on sprinklers (Yes/No)

Written Evacuation Plan(Yes/No)

Do alarms ring into central security desk or nurses stations?

Is smoking allowed in facility (Yes/No)

If yes describe:

# Enclosed Stairwells:

# Hours Fire Rating

# Other Stairwells

# Fire Escapes

Smoke Detectors (Yes/No)

Heat Detectors (Yes/No)

Central Station Alarm (Yes/No)

Are openings in floors or fire walls protected by fire doors, fire dampers, etc (Yes/No)

Self Closing Doors (Yes/No)

Hallways

Stairways

Sleeping Units

# of Elevators

Heat Sensitive (Yes/No)

HVAC System

Equipped with Combustion Detector (Yes/No)

Programmed for Automated Shutdown (Yes/No)

Complete Exhaust(Yes/No)

Emergency Notification System (Yes/No)

If yes, describe:

Are there more than one means of egress from each floor (Yes/No)

Written Evacuation plan posted in each room (Yes/No)

Operated by:

Applicant

Outside company

If outside company, does applicant have certificates of insurance on file (Yes/No)

Auto Extinguishing System (Yes/No)

UL 300 System (Yes/No)

Has required fuel shutoffs (Yes/No)

Covers all cooking and ventilation equipment (Yes/No)

Cooking Equipment #:

# Deep Fat Fryers

# Ranges

#Broilers

#Ovens

#Grilles

Other:

Is application compliance with both NFPA Standard #96 and UL 300 Standard (Yes/No)

Frequency of hood cleaning

Frequency of duct work cleaning

Professional hood and duct service firm used (Yes/No)

Name

Refrigeration maintenance agreement in place (Yes/No)

Name

Contract pest control services (Yes/No)

Any health code violations in last 3 years (yes/no)

Does the applicant contract with outside company to transport residents (Yes/No)

If yes, answer a, b and c below

(a) Provide name of company

(b) Does applicant require proof of insurance

(c)What limit of insurance does applicant require

Does applicant have owned have Autos (Yes/No)

# of Autos

Does applicant transport residents (Yes/No)

Any vehicles with more than 8 passenger capacity (Yes/No)

If yes, what is maximum seating

Seating Capacity

VEH #1

VEH #2

VEH #3

VEH #4

VEH #5

Age of vehicles

VEH #1

VEH #2

VEH #3

VEH #4

VEH #5

Are there designated drivers for owned vehicles (Yes/No)

If no, explain

Does applicant review MVR’s for all drivers (yes/no)

How frequent are MVRs reviewed for all drivers?

Are employees with MVR violations allow to operate vehicles (yes/no)

Does applicant drug test drivers (yes/no)

Is operation radius of vehicles local only (Yes/No)

If no, explain

Is there a certified driver training course for new drivers (Yes/No)

Are signatures obtained from both driver and trainer after satisfactory completion of driver training course (Yes/No)

Are there written protocols for the loading and unloading wheel chairs (Yes/No).

If yes, please include copy with submission

Do volunteers transport residents (yes/no)

Is there a preventative maintenance program performed for vehicles (yes/no)

Do employees transport resident in their own vehicles (Yes/No)

If yes, answer a and b below

(a) Describe transportation activities

(b) Does applicant require employees to maintain minimum limits of insurance (yes/no) If yes, specific limits

Do volunteers operate any vehicles? (Yes/No)