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Long Term Care Liability Insurance Application

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Procedure Questionnaire

THIS QUESTIONNAIRE IS PART OF THE APPLICATION, INCLUDING A RENEWAL APPLICATION, SUBMITTED BY OR ON BEHALF OF THE APPLICANT FOR THE PROPOSED INSURANCE. THE NOTICES, CONDITIONS, REPRESENTATIONS AND AUTHORIZATIONS CONTAINED IN SUCH APPLICATION ARE INCORPORATED INTO AND APPLY TO THIS QUESTIONNAIRE.

For each procedure below, please provide the approximate number of times you have “Performed” or “Assisted” during the past 12 months as well as how many times you anticipate doing so during the next 12 months. If you Perform or Assist in other procedures not listed below, add each one under “Other” in each section.

A. General Procedures

Alternative/Holistic Medicine (explain):

Abortions – Your Patients

1st Trimester

After 12 weeks

Angiography

Angioplasty

Anti-Aging Medicine (explain):

Arterial Catheterization

Arteriography

Bronchoscopy

CCU Care (other than admitting)

Chelation Therapy (explain):

Chemotherapy

Colonoscopy

Cardiac Catheterization

Cardiac Cath – Right Heart Only

Cryosurgery (explain):

Dilation & Curettage

Dialysis Procedures

Elective Cardioversion

Endoscopy (explain):

Hair Transplants

Hypnosis

IVP

Laser Therapy (explain):

Lymphangiography

Myelography

Paracentesis or Thoracentesis

Polypectomy by Endoscopy

Venography

Weight reduction or Weight Control

If “Yes,” % of practice:

List methods, drugs prescribed on a separate sheet of paper

Other (describe):

  None of the above

B. Gynecology Procedures

Abortions – Your Patients

1st Trimester

After 12 weeks

Therapeutic

Elective

Abortions – Other Patients

1st trimester

After 12 weeks

Therapeutic

Elective

Attach list of facilities where you perform abortions.

A&P Repair

Cervical Cautery

Cold Conization Cervix

Culdocentesis

Dilation & Curettage

Ectopic Pregnancy

Hysterectomy – Vaginal

Hysterectomy – Abdominal

Insertion of IUD

In Vitro Fertilization

If “Yes,” % of practice:

Laparoscopy

Office Gynecology

Oophorectomy or Salpingectomy

Tubal Ligation

Other (describe):

  None of the above

Do you own or operate a sperm bank for the treatment of your patients?

Do you own or operate a sperm bank for the treatment of others’ patients?

Yes No

Yes No

C. Pediatric Procedures

Circumcisions

Neonatology

If “Yes,” % of practice:

Umbilical Catheterization & Monitoring

Other (describe):

  None of the above

E. Surgical Procedures

Adenoidectomy

Anal Fissure

Anal Fistulectomies

Any surgical procedure involving cutting into or within the abdominal cavity, chest cavity, orbital cavity, spine or facial sinuses

Any surgical procedures on malignant lesions except for diagnostic purposes

Amputations

Appendectomies

Aspiration of Cyst of Breast

BCIR

Biopsies

If “Yes,” explain types:

Cholecystectomies – Open

Chymopapian Injections

Hemorrhoidectomies

Hernioplasties

Herniorrhaphy (Inguinal or Femoral Only)

Laparoscopic Cholecystectomies

Mastectomy

Mastoidectomy

Minor Office Surgery

Myringotomy

Nasal Polypectomy

Operations within the middle or inner ear

Organ Transplants

If “Yes,” explain:

Otorhinolaryngology

Peripheral Nerve Surgery

Prostatectomy

Reconstructive Vascular Surgery, Thromboembolectomy and/or Thrombectomy of the arteries or veins

Repair of laceration not involving nerve or tendon

Submucous Nasal Resections

Surgical treatment of cysts, superficial abscesses, minor traumatic wound & superficial biopsies

Surgical Weight Reduction

Thyroidectomy

Tonsillectomy

Vein Stripping

Other (describe):

  None of the above

D. Obstetrical Procedures

Amniocentesis – 3rd Trimester Only

Amniocentesis – 1st or 2nd Trimester

Breech Delivery

Cesarean Sections

Episiotomy

Low Forceps

Managing Toxemia

Mid Forceps

Normal Deliveries

Prenatal Care

Home Deliveries

Other Non-Hospital Deliveries (explain):

VBAC

Other (describe):

F. Urological Procedures

Any cutting into or on the kidney, ureter or bladder

Aspiration of Hydrocele

Circumcisions

Orchiectomy

Phalloplasty (including transecting the suspensory ligament of the penis and/or subcutaneous fat injection)

Prosthetic Implants

Sex Change Surgery

Treatment of Torsion of the Testicle

Vasectomy

Other (describe):

  None of the above

G. Anesthesia Procedures

Acupuncture

If “Yes,” for anesthesia? Yes No

Caudal

Digital Block

General

Intravenous Anesthesia

Intravenous Analgesia

Nitrous Oxide

Obstetrical Anesthesia

Pain Blocks

Pain Management

If “Yes,” please complete a Pain Management Questionnaire

Peripheral Nerve Block

Spinal Anesthesia

Other (describe):

If “Yes” for any Anesthesia type, check locations where performed:

Hospital    Surgicenter    Non-hospital facility

H. Plastic & Cosmetic Procedures

Autologous Fat Injection

Blepharoplasty (cosmetic)

Botox Injections

If “Yes,” location, by whom and what procedure/purpose?

Breast Reduction

Breast Enhancement – Silicone

Breast Enhancement – Saline

Breast Enhancement – Trans-Umbilical

Chemical Peels

Collagen Injections

Coronal Lift

Dermabrasion

Hair transplants or suturing of hair pieces

Injection Treatment of Varicose Veins

Laser Therapy (explain):

Prolotherapy

If “Yes,” do you use Phenol? Yes No

Laser vaginal rejuvenation (includes cosmetic and/or plastic surgery procedures performed on the vagina and associated structures. This includes, but is not limited to vaginoplasty, labiaplasty, laser and non-laser rejuvenation procedures).

Other Surgical Procedures (explain):

Liposuction – under 3500 ccs

Liposuction - 3500 ccs or more

Phalloplasty – including transecting the suspensory ligament of the penis and/or subcutaneous fat injection

Rhinoplasty

Silicone Implants (types and where)

Silicone Injections

Other (describe):

  None of the above

I. Orthopedic & Neurosurgical Procedures

Any operative orthopedics

Arthroscopy or Arthrography

Injection of Bursa

Joint Implants

Neuro Implant Surgery for Pain

Open Reduction of Fractures

Prolotherapy

If “Yes,” do you use Phenol? Yes No

Repair of Extensor Tendon

Repair of Flexor Tendon

Spinal Surgery

Anterior Cervical Discectomies

Cervical Laminectomies

Pedicle Screw

Scoliosis Surgery

Stereotactic Neurosurgery

Other (describe):

  None of the above

J. Ophthalmology Procedures

Automated Lamellar Keratotomy

Blepharoplasty (Cosmetic)

Blepharoplasty (Functional)

Cataract Surgery

Chalazion Excision from Eyelids

Corneal Transplants

Enucleation

Hexagonal Keratotomy (HK)

Intraocular Lens Implant

Iridectomy

LASIK

Lid-Repair – Ectropion & Entropion

Photo-Refractive Keratotomy (PRK)

Pterygium Excision

Refraction’s

If “Yes,” what type?

Removal of Eyelid Lesion

Retinal Detachments

Trabeculectomy

Treatment of Eye Infection

Other (describe):

  None of the above

SIGNATURE AND AUTHORIZATION

The undersigned, as authorized agent of all individuals and entities proposed for this insurance, represents that, to the best of his/her knowledge and belief, after reasonable inquiry, the statements in this questionnaire are true and complete.

The notices, conditions, representations and authorizations contained in the Application submitted by or on behalf of the Applicant for the proposed insurance, are incorporated into and apply to this questionnaire.

Applicant Name

By (Authorized Signature)

Name/Title

Date

Enter text✕
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What the Long Term Care Liability Insurance Application Is

The Long Term Care Liability Insurance Application is a standardized form insurers use to assess liability exposure for long-term care providers, assisted living facilities, and related operations. It collects applicant identity, facility characteristics, staffing and credentialing details, claims and loss history, risk management policies, and requested coverage terms. Underwriters use the completed application to evaluate eligibility, set premiums, determine exclusions, and decide whether to bind coverage. The application may be submitted on paper or electronically and, when properly executed, is subject to U.S. e-signature law including the ESIGN Act (15 U.S.C. ch. 96) and applicable state UETA or ESRA rules.

Why a Complete Application Matters

A thorough Long Term Care Liability Insurance Application ensures accurate underwriting, helps avoid coverage gaps, and reduces the chance of post-claim disputes by documenting operations, prior claims, and risk controls at the time of bind.

Why a Complete Application Matters

Who Typically Prepares and Submits This Application

Common preparers include risk managers, licensed agents, facility administrators, and third-party brokers who gather operational and claims information for underwriting.

  • Licensed insurance agents or brokers who complete applications on behalf of facility clients.
  • Facility managers or administrators who provide operational, staffing, and claims history details.
  • Risk management or compliance officers who document policies, training, and quality controls.

Accurate input from the operator combined with agent review speeds underwriting and produces a more reliable premium and coverage outcome.

Core Sections Found in a Professional Application

A well-structured Long Term Care Liability Insurance Application groups information into logical sections so underwriters can quickly assess exposures, identify prior losses, and confirm compliance with licensing and care standards.

Applicant Identity

Legal entity name, DBA, federal tax ID, mailing and physical addresses, primary contact and broker details to confirm legal responsibility and billing.

Facility Operations

Facility type, licensed bed count, occupancy rate, services offered (e.g., skilled nursing, memory care), and any subcontracted clinical services.

Staffing & Credentials

Staffing ratios, credential verification processes, continuing education, background checks, and any use of agency or per-diem staff.

Claims & Loss History

Completed claims history for specified prior years, open claims status, reserves, professional liability suits, and any regulatory complaints.

Risk Management

Policies for resident safety, medication administration, infection control, incident reporting, emergency planning, and staff training programs.

Coverage Requested

Desired limits, deductibles, retroactive dates (if applicable), and supplemental coverages such as regulatory defense or sexual abuse/molestation endorsements.

Step-by-Step: Completing the Application

Follow these steps to assemble, verify, and submit a complete application for underwriting review.

  • 01
    Gather documents: Collect licensure, claims runs, and policies for attachments.
  • 02
    Complete fields: Enter data accurately and use MM/DD/YYYY date format.
  • 03
    Attach records: Upload loss runs, licensure, inspection reports, and policies.
  • 04
    Submit to carrier: Send completed application and await underwriting requests.

Typical Electronic Submission Workflow

Electronic workflows mirror paper processes but add verification, attachments, and audit trails to support faster underwriting while preserving legal enforceability.

  • Upload application: Sender uploads PDF or DOCX version of the application.
  • Place fields: Add signature, date, and attachment fields where needed.
  • Authenticate signer: Use email, SMS code, or stronger verification as required.
  • Deliver to carrier: Submit signed package with audit trail and attachments.

Configure an Online Application Workflow

Set up field requirements, conditional sections, and signer authentication to match underwriting rules and regulatory constraints.

Required Fields Make core fields mandatory to prevent incomplete submissions.
Conditional Sections Show loss-history fields only if prior-claims indicator is 'Yes'.
Authentication Select email verification or SMS code per risk tolerance.
Attachments Require loss runs and licensure as PDF attachments.
Notifications Email broker and carrier on final submission automatically.

Platform and File Requirements for eSubmission

Confirm the eSignature platform supports required file formats, audit trails, and the authentication level your carrier requires before signing.

  • File Formats: PDF and DOCX preferred for structured forms.
  • Integrations: Connectors for Salesforce, NetSuite, and Google Workspace.
  • Security: TLS in transit and AES-256 at rest required.

Security and Compliance Essentials for Electronic Applications

Encryption: TLS 1.2/1.3 in transit; AES-256 at rest
HIPAA: HIPAA compliant when BAA executed
ESIGN / UETA: Compliant with ESIGN and state UETA
Audit Trail: Preserves timestamps, IP, and actions
Certifications: SOC 2 Type II and ISO 27001
21 CFR: Supports 21 CFR Part 11 requirements

Typical Timelines and Processing Expectations

Processing times depend on carrier workflow, completeness of attachments, and whether inspections or additional information are required.

Application Receipt:

Carrier acknowledges receipt within 1–3 business days.

Underwriting Review:

Typical review takes 7–21 business days depending on complexity.

Inspection / Survey:

On-site inspections scheduled within 7–30 days when required.

Additional Info Request:

Respond within 14 days to avoid delays.

Policy Issuance:

Policy issued upon underwriting approval and receipt of premium.

Key Milestones from Submission to Policy Delivery

A sequential view of major stages helps applicants track progress and anticipate required actions during underwriting.

01

Submit Application

Provide complete form and required attachments immediately.

02

Underwriting Review

Carrier evaluates exposures and may request clarifications.

03

Inspection and Survey

Carrier or vendor conducts physical or virtual inspections if needed.

04

Bind Coverage

Coverage is bound after acceptance and premium payment.

Common Preparation Mistakes to Avoid

  • Incomplete loss history or missing loss runs, which frequently result in additional underwriting requests and delayed decisions.
  • Mismatched legal names between the application and IRS or state filings, causing administrative holds or policy amendments.
  • Insufficient documentation of staff credentials and training, which can reduce offered coverage or increase premiums.
  • Failing to disclose regulatory actions or complaints, potentially leading to rescission or denial if discovered later.

Penalties and Risks of an Incorrect Application

Coverage Denial: Claims may be denied for material misrepresentation
Rescission Risk: Carrier can rescind policy for omitted facts
Delayed Coverage: Underwriting holds extend exposure without protection
Regulatory Fines: State insurance regulators may assess fines
Premium Adjustment: Underwriter may increase premium or add exclusions
Legal Liability: Facility faces higher litigation risk post-claim

Real-World Experiences with Electronic Application Workflows

Organizations across sectors report improved completion rates and clearer audit trails when using structured electronic forms and e-signatures.

Optica Ventures LLC

Their team standardized application intake and reduced follow-ups by centralizing attachments and contact data.

  • The platform simplified customer interactions.
  • "The interface is simple and easy-to-use for our team; more importantly, it is just as easy for our customers." — Brian Fitzgibbons, COO.

Martin Properties

Moved to electronic submission to ensure consistent signatures and complete documentation.

  • This reduced turnaround time significantly.
  • "I can process and execute all of these documents online with 100% compliance and built-in security. Whether on mobile or working offline, I can get forms back to their necessary parties efficiently." — Tim Martin, Founder.

Typical eSignature Vendor Pricing Comparison for This Use Case

Compare common vendor pricing and basic feature availability relevant to completing and e-signing Long Term Care Liability Insurance Applications.

signNow DocuSign Adobe Sign PandaDoc HelloSign
Starting Price $8/user/mo $15/user/mo $14/user/mo $19/user/mo $15/user/mo
Free Trial Yes, 7-day trial Varies by vendor Varies by vendor Varies by vendor Varies by vendor
Bulk Send Yes (Premium) Yes Yes Yes Limited
Audit Trail Yes Yes Yes Yes Yes
HIPAA Compliant Yes (BAA) Yes Yes No No
Envelope Cap No cap 100 envelopes/user/year Varies by plan Varies by plan Varies by plan

Frequently Asked Questions and Troubleshooting

Answers to common questions about electronic completion, signature validity, and correcting errors on Long Term Care Liability Insurance Applications.


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