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    • Home
    • About
    • Allied Health
    • Residential Facilities
    • Med Spas
    • Appetite
    • Applications
    • Marketing
    • Contact Us
  • Home
  • About
  • Allied Health
  • Residential Facilities
  • Med Spas
  • Appetite
  • Applications
  • Marketing
  • Contact Us

Applications (Outpatient Facilities)

NOTE: Adult day care centers, consultants, accounts with weight loss exposure, accounts with product sales/rental/installation exposure, and accounts with claims will also need to complete a supplement from the supplement section below. If any account would like sexual abuse and/or H&NOA coverage, please also request that the associated supplement be completed.

General Allied Health (04-25) (pdf)Download
Home Health & Staffing (04-25) (pdf)Download
Med Spa (04-25) (pdf)Download
Medical Arts School (04-25) (pdf)Download
Medical Director Application (04-25) (pdf)Download
Medical Labs (04-25) (pdf)Download
Non-Emergency Medical Transportation (04-25) (pdf)Download
Outpatient Mental Health Counseling & Substance Abuse Application (04-25) (pdf)Download
Pharmacies (04-25) (pdf)Download

Applications (Residential Facilities)

NOTE: If any account would like sexual abuse and/or H&NOA coverage, please also request that the associated supplement be completed.

Adult Residential Substance Abuse, Halfway House & Sober Living (04-25) (pdf)Download
Assisted Living and Group Homes (04-25) (pdf)Download

Supplements

Adult Day Care Supplement (04-25) (pdf)Download
Claims Supplement (04-25) (pdf)Download
Consultants Supplement (04-25) (pdf)Download
DME Supplement (04-25) (pdf)Download
H&NOA Supplement (04-25) (pdf)Download
Sexual Abuse Supplement (04-25) (pdf)Download
Weight Loss Supplement (04-25) (pdf)Download

Other Forms

Application Acceptance & Representation Statement (pdf)Download
No Known Loss Letter - General (04-25) (pdf)Download
No Known Loss Letter - H&NOA (04-25) (pdf)Download
No Known Loss Letter - Sexual Abuse (04-25) (pdf)Download

Balance Partners, LLC is a New York Limited Liability Company. In California, Balance Partners Insurance Services, LLC License #0M92717

https://www.balanceuw.com/policies-notices-and-disclosures 


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