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Date Issued:

Title 22 of the District of Columbia Municipal Regulations (DCMR), Public Health and Medicine, Subtitle C: Health Care and Community Residence, states that a Community Residence Facility (CRF) providing safe, hygienic, sheltered living arrangements for one or more individuals aged eighteen (18) years of older -- who are not related by blood or marriage to the Residence Director and who are ambulatory and able to perform the activities of daily living with minimal assistance -- shall carry sufficient insurance to cover hazards (five and extended coverage) and legal risk or liability.

I, ___________________________ (Signature of Residence Director)

Address

on this date authorize the release and verification of the requested information regarding my insurance policies. The maximum capacity of residents in my household is .

Insurance Company:

Address:

Please verify that the above-named operator has a current fire and/or liability insurance policy (policies) with your company that provides coverage for non-related residents who pay for their care.

Fire Insurance
Hazards (fire and extended coverage) in the amount of $500 per resident to protect belongings with a minimum of $2,000 of coverage per facility.
Amount:	$
Policy Number:
Expiration Date:
Liability Insurance
Premises personal injury and products:	$
Incidental malpractice coverage:	$
Policy Number:
Expiration Date:	$

Signature ______________________________         Date _________