General and Professional Liability General and Professional Liability Application Name of Agent Assisting You:* Name of Business:* Request Effective Date:* MM slash DD slash YYYY No. of Years of Ownership:* Current Liablility Carrier:* Current Property Carrier:* Premium Amount on Current Coverage:* Contact Name:* Phone Number:*Contact Email:* Number of Locations & StatesNumber of Locations & StatesStateType of FacilityBedsRequested Retro-Active Date CaliforniaTexasSkilled NursingIntermediate CareICFDDGroup HomeResidential CareIndependent LivingNo Current Coverage1 Year2 Years3 Years4 Years or more Please list any known losses, including the amounts of loss, years of loss, and causes of loss:Privacy Policy I agree to be contacted by Alera Group in accordance to their Privacy Policy as described below. By submitting this form, I agree I want to receive additional information from Alera Group, including by email, phone, and mail to the contact information I am submitting. I consent to Alera Group, its subsidiaries, and its service providers, processing my personal information for these purposes and as described in the Privacy Notice. I understand that I can withdraw my consent at any time.CAPTCHA Δ
