Commercial insurance: Yes No Self insurance: Yes No If self insurance, describe: Is there a fronting policy? Yes No Name of insured: Insurance company: Rating: Rater: Insurance company is licensed in the United States: Yes No Statute of limitations: Current coverage: Per occurrence: Aggregate: Deductible: Self insurance OR retention: Policy Basis: Per occurrence Claims made Current Expiration: Retroactive Date: Policy Premium: Summary of Six-Year Loss History for Operator or its Parent of Operator Total claims Total claims paid paid under this Total bed count under this policy policy covered under Dollars paid in Year (dollars) (no. of claims) the policy claims per bed 1 2 3 4 5 6 Total/average
Commercial insurance: Yes No Self insurance: Yes No If self insurance, describe: Is there a fronting policy? Yes No Name of insured: Insurance company: Rating: Rater: Insurance company is licensed in the United States: Yes No Statute of limitations: Current coverage: Per occurrence: Aggregate: Deductible: OR Self insurance retention: Policy Basis: Per occurrence Claims made Current Expiration: Retroactive Date: Policy Premium: Summary of Six-Year Loss History for Operator or its Parent of Operator Year Total claims paid under this policy (dollars) Total claims paid under this policy (no. of claims) Total bed count covered under the policy Dollars paid in claims per bed 1 2 3 4 5 6 Total/average