AmityFin || We keep our promises

Applicant Name *

Owner/Admin *

Address of Facility *

Address *

DBA *

Email *

Phone Number *

No of Beds *

Beds Occupied *

Business Operations: Assisted Living Assisted Living Both

No of Employees *

Full Time Employees*

Part Time Employees*

Date of Operation Started*

Number of Years Same Ownership*

Administrator Working Experience*

No of losses in last 5 years: None If Any Mention Date and Explain below

Description:*

Have you ever had coverage? Cancled Declined Non-Covered

If Yes Explain Below:*

Have you ever had insurance with National Assisted Living Risk Retention Group? Yes No

Is there a licensed Care Giver available 24 hours daily? LPN MEDTECH

What is average working hours per week?*

Is the facility a mixed population of young and elders? Yes No

Are fire, development, disaster drills conducted? Yes No