DAY CARE CENTER SUPPLEMENTAL APPLICATION

General Information, Customer Information:

1. Corporate Name:
2. Corporate Address:
3. Years in Business:
4. Contact Person, Name Phone Number

Property

1. Building Value:
2. Contents Value:

3.

Business Income Limit per month
and number of month coverage desired:
4. Year Built:
5. Type of Construction:
6. Square Footage:
7. Number of Stories:

Liability

1. Limit of Coverage Desired:
2. Any additional insureds:
3. Do you have a Swimming Pool:

Business Automobile

1. Limit of Coverage Desired:
2. Year
3. Make
4. Model
5. Seating Capacity of Vehicle(s):
6. Driver List including: Name, Date of birth, Drivers License Number

Application Information

1. The Center is located in:
2.

Does you Center exit directly
to the outside?

2a. and to ground level?
3. Does your Center have smoke detectors?
4. If the bathroom doors lock, can they
be unlocked from the outside?
5. The Center is licensed?
6. Has a license to operate ever been denied, has you license ever been suspended or revoked, or have you ever been brought up for a compliance hearing? If so, why?
7. If the Center has an after school program, how many are children enrolled in that program?
8. Location No.
9. Total Day Care Providers/Teachers
10. Total Children
11. Ages of children
9. Provide duties and ages of all staff under 18 years of age:
10. Based on the maximum number of children enrolled on your busiest day, what is your actual breakdown of total staff to total number of children by
age group?
11. There are _________ children enrolled
at the Center who are emotionally or physically handicapped or required special treatment due to existing medical problems. Describe disability, a age of child and special care provided by Center staff
12. There are ___________ children enrolled at the Center who require a special diets. Describe diet:
13. Do you have an accident/health policy?
13a. Is coverage mandatory for all students?
14. Do you utilize swimming facilities?
14a. If yes, are they
14b. If No, do you anticipate using swimming facilities in the future?
15. Employee background check includes personal references, police record check, education record check, physical/
emotional screening, etc.
16. A minimum of one staff member certified in First Aid is present at all times.
17. Do you provide sick child facilities?
17a. If yes, explain in space provided.
18. Is a file maintained on each child containing the following information?  
18a. Immunization records of the children being immunized successfully, and updated annually?
18b. Records for each child indicating unusual conditions the child has?
18c. Name of Parent/Guardian who will pick up the child on file and used?
18d. Signed releases for emergency medical treatment/dispensing of medication obtained from parents?
18e. Dispensing of childrenıs medication
is also subject to written instructions form physician?
19. Is there a playground?
19a. Is it fenced?
20. Are field trips taken?
20a. If Yes, explain type, frequency , and maximum distance from Center in space provided
20b. If no field trips provided currently, do you anticipate having them in the future?
20c. If yes, explain
20d. Is written permission obtained from each childıs parent or guardian?
20e. Is transportation hired with or without
a driver?
21. Food is handled, stored, and served in accordance with applicable government requirements?
22. Play equipment and toys met the consumer safety code requirements?
23. Are special classes ( gymnastics,
Dance, etc.) provided?
23a. If yes, explain
23b. If special classes are taught by an independent contractor on your premises, do you require them to provide proof of liability coverage
such as a certificate of insurance?
24. Driver screening/vehicle maintenance plan for passenger vehicles in effect?
25. Written emergency/security plan in effect?
26. Does the Center accept drop-in children for the day?
26a. If yes, explain drop-in policy and indicate approximate number drop-in children accepted weekly in the
space provided
27. Operations other than child care?
27a. If yes, explain
28. Does your application include questions about whether the individuals has even been convicted for any crime, including sex related or child abuse related offenses?
29. Do you verify employment
related references?
30. Do you have a plan of supervision that monitors staff in day-to-day relationships with clients both
on and off premises?
31 a. Has your organization ever had an incident which resulted in an allegation sexual abuse
31 b. If yes, please describe:
31 c. Was a claim made against the organization?
31 d. If yes, is that individual still employed with your organization?
31 e. Was the case settled?
32. Does your current Insurance program exclude Abuse & Molestation coverage?
  If not, please indicate the limit of liability provided:

This application and the loss information shown in Question 30 above are understood to be an inducement to the issuance of a policy of insurance by company and applicant warrants that all answers to questions are true and correct.