Effective Date: 



Updated 4/2005


The letters in the detailed instructions correspond to the form attached below.



A. — Number assigned to bond by insurer.

B. — Effective date of the bond (must be date of contract beginning, if new ownership).

C. — Must be same corporate name as on the contract with this department.

D. — Exact name of the facility as listed on the contract.

E. — Four-digit number, i.e. 4030 (owner number -2, not necessary)

F. — Physical street address of the nursing facility.

G. — City, state and zip code for physical address of the facility.

H. — Name of the insurance company issuing the bond.

I. — State in which the insurance company is located.

J. — Amount of the bond. Should be as much as the largest amount in the trust fund account on any given day of the month.

K.Original signature of the person designated Attorney-in-Fact on the Power of Attorney (xerox or fax copies cannot be accepted).

L. — City, state and ZIP code of the insurance company.

M.Original signature of the Officer of Corporation. If signed by anyone else, their title must also be included (xerox or fax copies of the signature cannot be accepted).

N. — Street (or P.O. Box), city, state and ZIP code of corporate headquarters.

P. — Maximum amount that was in trust fund account on any given day of the year preceding the date of the bond.

Q. — Largest amount estimated that will be in the trust fund account on any given day in the coming year.

Original Power of Attorney MUST be attached.

Resident Fund Surety Bond Form (Illustration)

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