THCA Liability Insurance Survey
Please fill out the information below and click the Submit button.

Nursing Facility Name
Nursing Facility Address
Owner Name
Ownership Status: Not-For-Profit Investor Owned Public Governmental
Contact Name (person completing survey)
Phone Number

State Fiscal Year ending:	8/31/2004	8/31/2005	8/31/2006	8/31/2007	8/31/2008

Number of licensed beds

Type of Policy Issuer	8/31/2004	8/31/2005	8/31/2006	8/31/2007	8/31/2008
Admitted (Licensed) Insurer
Eligible Surplus Lines Carrier
Texas JUA
Registered Risk Retention Group
Independently Procured Insurance Contract
Non-admitted Captive Insurance Company
Other

Coverage Type	8/31/2004	8/31/2005	8/31/2006	8/31/2007	8/31/2008
Occurrence
Claims Made
Other

Coverage Amounts	8/31/2004	8/31/2005	8/31/2006	8/31/2007	8/31/2008
Per Occurrence
Facility Aggregate
Policy Aggregate
Premium

Self Insured Retention Amounts	8/31/2004	8/31/2005	8/31/2006	8/31/2007	8/31/2008
Per Occurrence
Facility Aggregate
Policy Aggregate

Deductible Amount	8/31/2004	8/31/2005	8/31/2006	8/31/2007	8/31/2008
Per Occurrence
Facility Aggregate
Policy Aggregate

Excess Layers of Coverage	8/31/2004	8/31/2005	8/31/2006	8/31/2007	8/31/2008
Total excess coverage
Total excess premium

	8/31/2004	8/31/2005	8/31/2006	8/31/2007	8/31/2008
Are defense costs within policy limits	Yes No	Yes No	Yes No	Yes No	Yes No

Nursing Facility Professional and General Liability Loss Run Summary
(A)    Going back as far as 01/01/2005, report the date the accident or injury occurred at your facility
(B)    Report the date you were made aware of the claim
(C)    Report the date you settled or otherwise closed the claim
(D)    Was this claim the result of a filed lawsuit?
(E)    Describe the nature of the claim (i.e.- Wrongful Death, Bodily Injury, etc.)
(F)    Provide the cost of defending the claim including attorneys fees, expert witness costs etc)
(G)    Provide the total loss dollars paid, including co-pays, deductibles, primary and excess coverage.
(H)    Provide the total claim cost for this claim.

	(A)	(B)	(C)	(D)	(E)	(F)	(G)	(H)
Claim #	Occurrence Date	Reported Date	Closure Date	Lawsuit	Claim Type	Defense Cost	Total Loss Dollars Paid	Total Claim Cost
(example)	10/15/2005	3/15/2006	8/1/2008	Yes	Wrongful Death	25,000.00	75,000.00	100,000.00
				Yes No
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				Yes No