Childcare Insurance

CHILD CARE QUOTE FORM
The Quote Form is our preliminary process of obtaining the necessary underwriting information. Be as thorough as possible. The current policy and claim history will also be required as part of the underwriting process.
First Name Required
Last Name Required
Legal Name of Business (DBA) Required
Are you the Owner of the Business? Required	Yes No
If NO, what is your name and relationship to the business? Required
Provide the Business Website or indicate "None" if you do not have one Optional
Street Required
City Required
State Required	AL GA NC SC TN
ZIP / Postal Code Required
Primary Phone Number Required
E-Mail Address Required
Type of Child Care Center Optional	For Profit Not for Profit Cooperative Center(Funded & staffed by parents)
OPERATIONS
What type of building is the child care center located in? Optional	Commercial Religious Institution School Private Home Other
If you answered OTHER to previous question, please describe Required
Years in business with current management? Required
Hours of operation? Required
Are there any Camp Exposures? Required	Yes No
Are there any overnight stays? Required	Yes No
Is insured an exclusive After-School Facility? Required	Yes No
Does enrollment of handicapped students exceed 20%? Required	Yes No
LICENSING
Is the child care center a licensed facility? Required	Yes No
Has a license to operate ever been denied, suspended or revoked? Required	Yes No
If YES, please explain Required
Date of the most recent state inspection? Required
Have you ever received any citations or warnings issued by any state or government entity? Required	Yes No
If YES, please explain details Required
PREMISES CHARACTERISTICS
Is the center a standalone structure or is it located within a multi-use building? Required	Yes No
Was the structure built after 1978? Required	Yes No
Was the structure built specifically for child care or modified for that particular purpose? Required	Yes No
Is the facility on grade level with two exits? Required	Yes No
Is there a swimming pool or water exposure? Required	Yes No
Does your center operate a full kitchen on site? Required	Yes No
Does your center have a Central Station fire detection system? Required	Yes No
Are there manual pull stations? Required	Yes No
Are fire extinguishers inspected and tagged annually? Required	Yes No
When was the last inspection date? Required
Does your center have smoke detectors? Required	Yes No
Are the smoke detectors battery operated or hard wired? Required	Battery Operated Hard-Wired to the Building No Smoke Detectors
Are there protection covers on all electrical outlets? Required	Yes No
STAFF and CHILDREN
How many days per week do you operate? Required
What is your average daily attendance(including full and part-time children)? Required
What is the estimated square footage of child care area? Required
Highest enrollment counts for previous 4 years? Required
Expected enrollment for next year? Required
Caregiver/Teacher/Child ratio for Children Age 0 - 1? (State none, if n/a) Required
Caregiver/Teacher/Child Ratio for Children Age 1 - 2? Required
Caregiver/Teacher/Child ratio for Children Age 2 - 4? Required
Caregiver/Teacher/Child ratio for Children Age 4 - 5? Required
Caregiver/Teacher/Child ratio for Children Age 5 - up? Required
Is Teacher/Staff professionally qualified? Required	Yes No
Are all caregivers currently licensed or certified? Required	Yes No
If NO, explain: Required
Are reference checks conducted for all staff? Required	Yes No
Is a minimum of one staff member certified in first aid present at all times? Required	Yes No
Are Teachers/staff trained to look for signs of mental and physical abuse? Required	Yes No
Are volunteers used? Required	Yes No
Are field trips taken? Required	Yes No
If YES, are signed release forms obtained from parents? Required	Yes No
If YES, are children required to wear identification while on field trips? Required	Yes No
Describe field trip activities and procedures Required
PLAY AREAS
Does the facility have its own play area? Required	Yes No
Is playground fenced and in compliance with state regulations? Required	Yes No No Playground
If NO, please explain Required
List all playground equipment and specify any with platform heights of over 6 feet Required
Are any trampolines, moonwalks, bounce equipment, inflatables, gymnastics equipment, wall climbing or ball pits present? Required	Yes No
Describe playground surface Optional
AUTOMOBILE
Does Insured provide student transportation to/from home? Required	Yes No
If field trips are taken, what is the radius of operation? Required
If field trips are taken, what is the frequency? Required
If field trips are taken, where do you go? Required
Is there a scheduled preventative maintenance program in place? Required	Yes No
Are all drivers that transport students over the age of 21 with acceptable MVR's? Required	Yes No
Do you operate any non-conforming vans (11 to 15 passengers)? Required	Yes No
Do employees or volunteers drive their own vehicles for company business? Required	Yes No
How often does this occur? Required
Do you require evidence that they have their own auto insurance? Required	Yes No
SAFETY
Is a record of injuries/treatment kept? Required	Yes No
Is child's medical history required? Required	Yes No
Does the child care center administer any medications? Required	Yes No
Are signed releases for emergency medical treatment/dispensing of medication obtained from parents? Required	Yes No
Are Pre-authorization records kept for child release? Required	Yes No
Is a release signed for transportation of sick/injured children? Required	Yes No
Is an Emergency situation procedure in place? Required	Yes No
Does the center have children sleeping at any time? Required	Yes No
If YES, are there Carbon Monoxide detectors installed within 15' of the primary entrance to each room lawfully used for sleeping? Optional	Yes No
CORPORAL PUNISHMENT
What is the Child Care Center's policy on corporal punishment? Required
Is there a written policy concerning the use of corporal punishment? Required	Yes No
Have there ever been any claims for corporal punishment? Required	Yes No
What are the Stte's laws on corporal punishment? Required	Allowed Prohibited
SWIMMING POOL/WATER CHECKLIST (Complete only if facility has a swimming pool/water exposure on or off premises)
FENCING
4' foot enclosure fencing or wall? Optional	Yes No
Self-closing gate and latch? Optional	Yes No
Locking hardware? Optional	Yes No
RULES & REGULATIONS
Posted pool hours and regulations? Optional	Yes No
Are children ages three and under restricted to shallow end? Optional	Yes No
Glass container rules? Optional	Yes No
Food consumption rules? Optional	Yes No
EMERGENCY INFORMATION
Emergency phone numbers posted? Optional	Yes No
Phone near pool area? Optional	Yes No
Emergency Plan in place? Optional	Yes No
PERSONNEL
Is there a certified lifeguard on duty? Optional	Yes No
If there an enforced staff and child ratio enforced? Optional	Yes No
Are the staff trained in CPR/First Aid as per state mandates? Optional	Yes No
LIFESAVING EQUIPMENT
15' foot pole or shepherd's hook? Optional	Yes No
18" inch ring or buoy and throwing rope? Optional	Yes No
Lifeline with floats to separate shallow and deep areas? Optional	Yes No
POOL
Depth - Shallow Area Optional
Depth - Deep Area Optional
2 sets of steps, ladders or stairs? Optional	Yes No
Steps & rung slip resistant? Optional	Yes No
4" inch depth markings? Optional	Yes No
Diving board provided? Optional	Yes No
Slide provided? Optional	Yes No
Wading pool? Optional	Yes No
Deck material slip resistent? Optional	Yes No
CHILD CARE LEGAL LIABILITY - CLAIMS-MADE BASIS (Complete only if this coverage is being requested)
Limits of liability requested for each loss? Optional
Limits of liability requested in aggregate for each annual policy year? Optional
If the child care organization has been in existence less than three years, was this organization an offshoot from another? Optional	Yes No
If YES, name of original organization? Optional
Number of members comprising the governing board of the institution? Optional
Number of Administrators? Optional
Number of Officials? Optional
Number of Teachers? Optional
Number of all other employees? Optional
What is the total current budget of your institution? Optional
What is the total accumulated deficit or surplus of your institution? Optional
How many years in the past five has there been a deficit? Optional
How many years in the past five years has there been a surplus? Optional
If there is a deficit, what is being done to eliminate it? Optional
CLAIMS
Has there been any claim in the past five years involving employee's tenure, dismissal, strikes, demotion or other employment related activities? Optional	Yes No
Has there been any claims in the past five years involving segregation, civil rights action involving children or employees? Optional	Yes No
Has there been any other type claim filed under a previous Legal Liability policy? Optional	Yes No
Are there any incidents that have not yet been reported or are known about that a claim has not been presented that might afford grounds for any future claim that would fall within the scope of this proposed insurance? Optional	Yes No
If you answered YES to any of the prior 4 questions, please attach a sheet outlning the date, facts, and any reserves, demands or judgments. Optional
Has similar insurance been declined, canceled or a renewal refused? Optional	Yes No
If YES, please explain Required
Who was your previous carrier for similar insurance coverage? Optional
ABUSE OR MOLESTATION LIABILITY (Complete only if this coverage is being requested.)
Has the insured ever had any abuse or molestation (inclding sexual misconduct or sexual molestation) claims? Optional	Yes No
Is there a record or knowledge of any previous incidents which might have resulted in such claims if they had been pursued? Optional	Yes No
If you answered YES to either of the two prior questions, please provide details. Optional
Does your organization have written policies that require known or suspected abuse incidents to be reported to the proper authorities? Optional	Yes No
Are employees and volunteers required to sign an ackowledgement of receipt and understanding of the abuse and sexual harassment policy? Optional	Yes No
Is documentation maintained on annual training regarding abuse, molestation and sexual misconduct provided to staff, students and volunteers? Optional	Yes No
Is the insured's facility open to parental visits? Optional	Yes No
Is Education verified on employees? Optional	Yes No
Is Education verified for Volunteers? Optional	Yes No
Are personal references checked for employees? Optional	Yes No
Are personal references checked for volunteers? Optional	Yes No
Are written applications required for employees? Optional	Yes No
Are written applications required for volunteers? Optional	Yes No
Are State level 10-digit fingerprint criminal record checks required for employees? Optional	Yes No
Are State level 10-digit fingerprint criminal record checks required on volunteers? Optional	Yes No
Are Federal level 10-digit fingerprint criminal record checks required on employees if in the State less than five years? Optional	Yes No
Are Federal level 10-digit fingerprint criminal record checks required on volunteers who live in the state less than five years? Optional	Yes No
Are Federal level 10-digit fingerprint criminal record checks required for emploees regardless of time in state? Optional	Yes No
Are Federal level 10-digit fingerprint criminal record checks required for volunteers regardless of time in state? Optional	Yes No
Are all controls previously listed required before an employee can have contact with children/clients? Optional	Yes No
Are all controls previously listed required prior to volunteer contact with children/clients? Optional	Yes No
Are checks conducted for Alias names for employees? Optional	Yes No
Are checks conducted for Alias Names for volunteers? Optional	Yes No
Are Multi-State Crimnial Background Checks conducted for employees? Optional	Yes No
Are Multi-State Criminal Background Checks conducted for volunteers? Optional	Yes No
Is the National Sex Offender Registry checked regarding employees? Optional	Yes No
Is the National Sex Offender Registry checked for volunteers? Optional	Yes No
Are Social Security Number traces done for employees? Optional	Yes No
Are Social Security Number traces done on volunteers? Optional	Yes No
How long are records dept docuenting all screening activities outlined above for employees? Optional
How long are records kept documenting all screening activities outlined above for volunteers? Optional
Has the insured developed and publicized to employees and volunteers abuse, molestation and sexual harassment reporting and investigation procedures? Optional	Yes No
Have persons charged with complaint management and investigation been adequately trained in these responsibilities? Optional	Yes No
Is there any child care/school exposure which is not run by the insured? Optional	Yes No
If YES, do the operators of such exposure have their own liability insurance, including coverage for abuse or molestation (including sexual misconduct or sexual molestation), with lmiits at least equal to those being requested hereunder? Optional	Yes No
Is our Insured named as additional insured on the operator's liability policy which includes coverage for abuse or molestation (including sexual misconduct or sexual molestation)? Optional	Yes No
Is there anything else that you would like for us to know concerning your quote request? Optional
The undersigned authorized officer of the Applicant/Insured entity declares that he/she has read the responses set out in the Child Care Application and that such responses/statements are true and accurate to the best of the officers knowledge and belief.
Typing your name here represents your valid signature (Must be President, Secretary or other authorized officer) Required
Please provide your TITLE Required
Please provide the DATE that you are signing Required
For Security of your personal information, enter code and press submit.
Submission Validation Required	Enter the Validation Code from above.

Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages.  Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company.  If you have any questions, please feel free to contact us.

Per the terms of our online privacy policy we will not resell your information to any third-party.

Insurance Websites Designed and Hosted by Insurance Website Builder