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Childcare Insurance

D. Ward Insurance Services, Inc. since 1988

Daycare Insurance since 1988
Multiple Carriers Compete

Our Highly Rated Carriers:

Hartford * Auto Owners * Progressive * Utica * US Liability * Mercury, and more.

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 *

Last Name *

Legal Name of Business (DBA) *

Are you the Owner of the Business? *

Yes
No

If NO, what is your name and relationship to the business? *

Provide the Business Website or indicate "None" if you do not have one

Street *

City *

State *

ZIP / Postal Code *

Primary Phone Number *

E-Mail Address *

Type of Child Care Center

For Profit
Not for Profit
Cooperative Center(Funded & staffed by parents)

OPERATIONS

What type of building is the child care center located in?

Commercial
Religious Institution
School
Private Home
Other

If you answered OTHER to previous question, please describe *

Years in business with current management? *

Hours of operation? *

Are there any Camp Exposures? *

Yes
No

Are there any overnight stays? *

Yes
No

Is insured an exclusive After-School Facility? *

Yes
No

Does enrollment of handicapped students exceed 20%? *

Yes
No

LICENSING

Is the child care center a licensed facility? *

Yes
No

Has a license to operate ever been denied, suspended or revoked? *

Yes
No

If YES, please explain *

Date of the most recent state inspection? *

Have you ever received any citations or warnings issued by any state or government entity? *

Yes
No

If YES, please explain details *

PREMISES CHARACTERISTICS

Is the center a standalone structure or is it located within a multi-use building? *

Yes
No

Was the structure built after 1978? *

Yes
No

Was the structure built specifically for child care or modified for that particular purpose? *

Yes
No

Is the facility on grade level with two exits? *

Yes
No

Is there a swimming pool or water exposure? *

Yes
No

Does your center operate a full kitchen on site? *

Yes
No

Does your center have a Central Station fire detection system? *

Yes
No

Are there manual pull stations? *

Yes
No

Are fire extinguishers inspected and tagged annually? *

Yes
No

When was the last inspection date? *

Does your center have smoke detectors? *

Yes
No

Are the smoke detectors battery operated or hard wired? *

Battery Operated
Hard-Wired to the Building
No Smoke Detectors

Are there protection covers on all electrical outlets? *

Yes
No

STAFF and CHILDREN

How many days per week do you operate? *

What is your average daily attendance(including full and part-time children)? *

What is the estimated square footage of child care area? *

Highest enrollment counts for previous 4 years? *

Expected enrollment for next year? *

Caregiver/Teacher/Child ratio for Children Age 0 - 1? (State none, if n/a) *

Caregiver/Teacher/Child Ratio for Children Age 1 - 2? *

Caregiver/Teacher/Child ratio for Children Age 2 - 4? *

Caregiver/Teacher/Child ratio for Children Age 4 - 5? *

Caregiver/Teacher/Child ratio for Children Age 5 - up? *

Is Teacher/Staff professionally qualified? *

Yes
No

Are all caregivers currently licensed or certified? *

Yes
No

If NO, explain: *

Are reference checks conducted for all staff? *

Yes
No

Is a minimum of one staff member certified in first aid present at all times? *

Yes
No

Are Teachers/staff trained to look for signs of mental and physical abuse? *

Yes
No

Are volunteers used? *

Yes
No

Are field trips taken? *

Yes
No

If YES, are signed release forms obtained from parents? *

Yes
No

If YES, are children required to wear identification while on field trips? *

Yes
No

Describe field trip activities and procedures *

PLAY AREAS

Does the facility have its own play area? *

Yes
No

Is playground fenced and in compliance with state regulations? *

Yes
No
No Playground

If NO, please explain *

List all playground equipment and specify any with platform heights of over 6 feet *

Are any trampolines, moonwalks, bounce equipment, inflatables, gymnastics equipment, wall climbing or ball pits present? *

Yes
No

Describe playground surface

AUTOMOBILE

Does Insured provide student transportation to/from home? *

Yes
No

If field trips are taken, what is the radius of operation? *

If field trips are taken, what is the frequency? *

If field trips are taken, where do you go? *

Is there a scheduled preventative maintenance program in place? *

Yes
No

Are all drivers that transport students over the age of 21 with acceptable MVR's? *

Yes
No

Do you operate any non-conforming vans (11 to 15 passengers)? *

Yes
No

Do employees or volunteers drive their own vehicles for company business? *

Yes
No

How often does this occur? *

Do you require evidence that they have their own auto insurance? *

Yes
No

SAFETY

Is a record of injuries/treatment kept? *

Yes
No

Is child's medical history required? *

Yes
No

Does the child care center administer any medications? *

Yes
No

Are signed releases for emergency medical treatment/dispensing of medication obtained from parents? *

Yes
No

Are Pre-authorization records kept for child release? *

Yes
No

Is a release signed for transportation of sick/injured children? *

Yes
No

Is an Emergency situation procedure in place? *

Yes
No

Does the center have children sleeping at any time? *

Yes
No

If YES, are there Carbon Monoxide detectors installed within 15' of the primary entrance to each room lawfully used for sleeping?

Yes
No

CORPORAL PUNISHMENT

What is the Child Care Center's policy on corporal punishment? *

Is there a written policy concerning the use of corporal punishment? *

Yes
No

Have there ever been any claims for corporal punishment? *

Yes
No

What are the Stte's laws on corporal punishment? *

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?

Yes
No

Self-closing gate and latch?

Yes
No

Locking hardware?

Yes
No

RULES & REGULATIONS

Posted pool hours and regulations?

Yes
No

Are children ages three and under restricted to shallow end?

Yes
No

Glass container rules?

Yes
No

Food consumption rules?

Yes
No

EMERGENCY INFORMATION

Emergency phone numbers posted?

Yes
No

Phone near pool area?

Yes
No

Emergency Plan in place?

Yes
No

PERSONNEL

Is there a certified lifeguard on duty?

Yes
No

If there an enforced staff and child ratio enforced?

Yes
No

Are the staff trained in CPR/First Aid as per state mandates?

Yes
No

LIFESAVING EQUIPMENT

15' foot pole or shepherd's hook?

Yes
No

18" inch ring or buoy and throwing rope?

Yes
No

Lifeline with floats to separate shallow and deep areas?

Yes
No

POOL

Depth - Shallow Area

Depth - Deep Area

2 sets of steps, ladders or stairs?

Yes
No

Steps & rung slip resistant?

Yes
No

4" inch depth markings?

Yes
No

Diving board provided?

Yes
No

Slide provided?

Yes
No

Wading pool?

Yes
No

Deck material slip resistent?

Yes
No

CHILD CARE LEGAL LIABILITY - CLAIMS-MADE BASIS (Complete only if this coverage is being requested)

Limits of liability requested for each loss?

Limits of liability requested in aggregate for each annual policy year?

If the child care organization has been in existence less than three years, was this organization an offshoot from another?

Yes
No

If YES, name of original organization?

Number of members comprising the governing board of the institution?

Number of Administrators?

Number of Officials?

Number of Teachers?

Number of all other employees?

What is the total current budget of your institution?

What is the total accumulated deficit or surplus of your institution?

How many years in the past five has there been a deficit?

How many years in the past five years has there been a surplus?

If there is a deficit, what is being done to eliminate it?

CLAIMS

Has there been any claim in the past five years involving employee's tenure, dismissal, strikes, demotion or other employment related activities?

Yes
No

Has there been any claims in the past five years involving segregation, civil rights action involving children or employees?

Yes
No

Has there been any other type claim filed under a previous Legal Liability policy?

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?

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.

Has similar insurance been declined, canceled or a renewal refused?

Yes
No

If YES, please explain *

Who was your previous carrier for similar insurance coverage?

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?

Yes
No

Is there a record or knowledge of any previous incidents which might have resulted in such claims if they had been pursued?

Yes
No

If you answered YES to either of the two prior questions, please provide details.

Does your organization have written policies that require known or suspected abuse incidents to be reported to the proper authorities?

Yes
No

Are employees and volunteers required to sign an ackowledgement of receipt and understanding of the abuse and sexual harassment policy?

Yes
No

Is documentation maintained on annual training regarding abuse, molestation and sexual misconduct provided to staff, students and volunteers?

Yes
No

Is the insured's facility open to parental visits?

Yes
No

Is Education verified on employees?

Yes
No

Is Education verified for Volunteers?

Yes
No

Are personal references checked for employees?

Yes
No

Are personal references checked for volunteers?

Yes
No

Are written applications required for employees?

Yes
No

Are written applications required for volunteers?

Yes
No

Are State level 10-digit fingerprint criminal record checks required for employees?

Yes
No

Are State level 10-digit fingerprint criminal record checks required on volunteers?

Yes
No

Are Federal level 10-digit fingerprint criminal record checks required on employees if in the State less than five years?

Yes
No

Are Federal level 10-digit fingerprint criminal record checks required on volunteers who live in the state less than five years?

Yes
No

Are Federal level 10-digit fingerprint criminal record checks required for emploees regardless of time in state?

Yes
No

Are Federal level 10-digit fingerprint criminal record checks required for volunteers regardless of time in state?

Yes
No

Are all controls previously listed required before an employee can have contact with children/clients?

Yes
No

Are all controls previously listed required prior to volunteer contact with children/clients?

Yes
No

Are checks conducted for Alias names for employees?

Yes
No

Are checks conducted for Alias Names for volunteers?

Yes
No

Are Multi-State Crimnial Background Checks conducted for employees?

Yes
No

Are Multi-State Criminal Background Checks conducted for volunteers?

Yes
No

Is the National Sex Offender Registry checked regarding employees?

Yes
No

Is the National Sex Offender Registry checked for volunteers?

Yes
No

Are Social Security Number traces done for employees?

Yes
No

Are Social Security Number traces done on volunteers?

Yes
No

How long are records dept docuenting all screening activities outlined above for employees?

How long are records kept documenting all screening activities outlined above for volunteers?

Has the insured developed and publicized to employees and volunteers abuse, molestation and sexual harassment reporting and investigation procedures?

Yes
No

Have persons charged with complaint management and investigation been adequately trained in these responsibilities?

Yes
No

Is there any child care/school exposure which is not run by the insured?

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?

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)?

Yes
No

Is there anything else that you would like for us to know concerning your up and coming Renewal?

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) *

Please provide your TITLE *

Please provide the DATE that you are signing *

For Security of your personal information, enter code and press submit.

Submission Validation

Required

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.

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