Homcare Company Information Updates

Home Care Services Information Update

You may use this form to update your organizations information. Please review the information for accuracy before submitting. This update is not a substitute for submitting evidence of business licence and proof of insurance. Once the submission has been received you will recieve a confirmation email. You may be contacted by phone to clarify your submission. Updates will be processed withing 2 weeks of confirmation.

* (denotes required field)

Name: *

E-Mail Address: *

Organization Information

Name of Company *

Main Address *

Alternative Addresses

Main Phone Phone Numbers *

Alternative Phone Numbers

Website

My business curently carries all of the following insurance coverages (General Liability and for caregivers providing transportation + workers comp + fidelity bonding) <b><u>Proof of coverage will be requested</u></b>: *

Yes
No

My business has a current business license (Proof of license will be requested): *

Yes
No

Background check (Please include the name address, phone number and web address of the company you use as well as any other informationdescribing your background check procedures for hiring caregivers) *

Services Provided

The following services are offered by our caregivers(Check all that apply): *

Homemaker
Personal Care
Transportation
Shopping Assistance
Organization
Respite
24 Hour Shifts
Pet Care

Other Information about my businesses services I would like to be included in my listing (limited to 250 Characters):

Financial Information

Hourly fee range (in dollars per hour): *

24 our shift rate (In dollars per 24 hour shift) *

Do you collect a deposit? If so what is the deposit for and how much? *

Which of the following best descibes your service agreement: *

Time specific contract (ie 1 year service contract)
Month to month agreement
On going serivce agreement with a notice period for termination or modification
No contract or service agreement
Other

<h3>Service Area</h3> *

North SLO County
North Coast SLO County
San Luis Obsipo including Los Osos and Avila Beach
5 Cities and South SLO County
Santa Maria Valley
Lompoc
Santa Ynez Valley
South Santa Barbara County

Message:

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