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.