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Best number for reaching you?
How do you prefer to be contacted?
- Telephone
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Additional Details (optional)
If you are seeking a quote for your AFH (or BHF) and can provide additional information now, we will be able to serve you more effectively and promptly. Alternatively. we can gather these details during follow-up communication:
- I want to provide these details now.
- I'll provide additional details later.
Alternate phone number
Fax number
Address of facility
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Different mailing address?
- Yes
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Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
What is the name of your Adult Family Home?
Do you own or rent the facility location?
- Rent
- Own
How many residents do you currently have?
How many residents are you licensed for?
How many of your residents are ambulatory?
Name of current insurance company (if applicable):?
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