2021-11-23_scygan_Montreal - CA.docx

Property & Casualty Acquisition Form

Insured:  Home Care Assistance of CA, LLC

Names to be added to policy: HCA Home Care Assistance Canada, Inc.

FEIN (if stock purchase):

Acquisition Type:	Stock	Asset	Other Address (provide separate list if more than one location:

HCA Home Care Assistance Canada, Inc.

4464 Saint-Catherine St W, Westmount,

Quebec H3Z 1R7, Canada

Effective date of acquisition: 10/21/2021	Y	Actual 			Estimated

Property – see attached lease

Year Built:

Construction Type:	Square Feet:

# of Stories:	Sprinklered:

Alarm:

BPP:

Please include copy of Lease / Loan Requirements

Auto - Provide List of Autos to Include – Not applicable.

Year:	Make:	Model:

VIN:	Cost New:

Driver information for the vehicle - Provide List of Drivers to include

First Name:	Last Name:

License #:				DOB:					State Licensed:

General Liability:

Provide annual payroll for the home health workers (not clerical or admin workers):___________ ___________________________________

Estimated annual revenue:_______________________________

Provide The number of full time home health care employees and the number of part time home health care employees: __________________