Trade Name of Business:
E-MAIL Address:
Legal Name of operating Entity:
Street Address of Center
City, State, & Zip
Phone Number
Contact Person
Number of Years in Business
Name of Current Insurance Company
Current Annual Premiums (Optional)
Coverages Currently Carried:
Property
General Liability
Loss of Income
Money and Securities
Work Comp
Commercial Auto
Commercial Umbrella
Abuse & Molestation
List any of the above coverages
which are not currently provided, but desired
Claims History - List details of all claims in the last three years.
Licensing Agency
Number of years Licensed
Number of children on License
Owner's Experience and Education:
Is there a pre-employment background check, including personal reference,
police record, education, physical/emotional? Yes No
Does child to staff ratio meet licensing requirements? Yes No
Are children released only to authorized persons? Yes No
Are all children ambulatory? Yes No
If not, explain:
Hours of operation:
Monday-Friday:
Weekend
Any overnight care? Yes No
Number of overnight children?
Do you have a swimming pool? Yes No
If "Yes," additional questionnaire is needed.
Do you use swimming facilities off premises? Yes No
If "Yes," does the pool provide lifeguards? Yes No
Do you require a liability disclaimer to be signed? Yes No
Please forward a copy of the required liability disclaimer.
Any pets on premises? Yes No
If "Yes," what kind and how are they contained?
Are they separated from children? Yes No No Pets
Any classes taught in dance, tumbling, gymnastics, or martial arts? Yes No
Are medical releases obtained at enrollment? Yes No
Is medication dispensed only by written instructions? Yes No
Is emergency transportation available? Yes No
How are illnesses and injuries handled?
Are there working smoke detectors? Yes No
Is there a working fire extinguisher? Yes No
Date last serviced:
Is center located in home? Yes No
Property Coverage Information
Type of Structure (Select One):
Frame
Brick w/wood joists
Brick & Block w/concrete & Steele Roof and Floors
Year Built
Are Sprinklers Present? Yes No
Distance to Fire Hydrant
Distance to Fire Department
Amount needed to replace all equipment, furniture
and fixtures, tenants improvements and betterments
If building coverage is desired,
amount needed to replace the building
Maximum amount of cash on hand at any one time
General Liability Coverage Information:
Limit of coverage desired:
$300,000
$500,000
$1,000,000
Sexual abuse & molestation limit desired:
$300,000
$500,000
$1,000,000
Umbrella limit desired:
None
$1,000,000
$2,000,000
$3,000,000
$4,000,000
$5,000,000
More
Number of Square Feet Occupied
Work Comp Coverage Information:
Federal Employee ID Number
Names of Corporate Officers, and do they
want to be covered (Included/Excluded):
Corporate Officer #1:
Name: Include Exclude
Corporate Officer #2:
Name: Include Exclude
Corporate Officer #3:
Name: Include Exclude
Corporate Officer #4:
Name: Include Exclude
Payroll for code 8869 - Day Care Professional Employees
Payroll for code 9059 - Day Care all other Employees
Automobile
Please call for a quote on commercial auto insurance.
ADULT DAY CARE SUPPLEMENTAL QUESTIONS
(all questions referring to children above also apply to adult attendees)
What is the maximum number of participants at any one time?
What is the average daily attendance?
Please describe all activities at this facility:
Is financial counseling provided? Yes No
Is Medical counseling provided? Yes No
Describe any special equipment on premises:
Are there an Alzheimer's afflicted adults? Yes No
If "Yes," how many, and maximum global level accepted?
Is there a doctor on staff or on call? Yes No
If "Yes," give details:
Is physical therapy provided? Yes No
If "Yes," give details:
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