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Group Home Insurance Application

Thank you for working with Blackridge Risk Partners. This application covers your group home program, including professional and general liability, hired and non-owned auto, abuse and molestation, and workers' compensation coverage.

Please answer every question. Where a question doesn't apply, answer "No" or "None" rather than leaving it blank. Questions? Call 385.214.5730.

Applicant information

Business name of applicant (including DBAs)

As it should appear on the policy.

Contact name

Contact email

Contact phone

Mailing address

Federal Employer Identification Number (FEIN)

Business entity type

A
B
C
D
E

Website

Physical address of all locations seeking coverage

Include street, city, state and ZIP for each location.

Number of years in business

Total staff count

Number of staff with direct client contact

Annual staff turnover rate (%)

Classification

Total number of licensed beds

Current number of occupied beds

Estimated annual revenue (next 12 months)

Estimated total annual payroll (next 12 months)