Downloading a Form to Your Computer
Fillable forms cannot be viewed on mobile or tablet devices. Follow the steps below to download and view the form on a desktop PC or Mac.
- Right Click for PC or Ctrl + Click for Mac on the PDF link and click “Save link as” from the menu.
- Select the folder you want to save the file in and then click "Save."
- Navigate to the folder you saved the file in and Right Click for PC or Ctrl + Click for Mac, then select "Open With" from the menu and select Adobe Acrobat Reader DC.
Note: Open the PDF file from your desktop or Adobe Acrobat Reader DC. Do not click on the downloaded file at the bottom of the browser since it will not open the PDF in Adobe Acrobat Reader DC. It will try to open the file in the browser that results in the same browser error message.
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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.