1. Proposed effective date:

   Liability occurrence limits: $500,000 $1,000,000

   Sexual Abuse limits: $50,000/$100,000       $100,000/$200,000
                                  $100,000/$300,000      $250,000/$500,000
                                  $500,000/$1,000,000    $1,000,000/$1,000,000

   [If an umbrella is requested, sexual abuse limits must be $1,000,000/$2,000,000 ­ check here ]

2. Named Insured (as to appear on policy):

3. Address:

   City: State: Zip:

   Home Phone: Fax Phone:

   Email Address: Website Address:

4. Business type:
   1. Individual Corporation Partnership LLC
      Other:

   2. Profit Nonprofit

   3. Commercial Child Care no camp Commercial Child Care with camp Montessori Nursery School Head Start Sick Child Facility (Percent of enrollment devoted to sick child care:%)
      In-Home care Private school (Please complete a Private School application) Other:

   4. Federal Employer ID No.

   5. Are you a member of: NAEYC? NCCA? NACCP?
                                       Other:

5. Is the facility accredited by any of the following?

   NCCA NAFCC NACCP NAEYC
   Other: (Certificate must be mailed in)

6. Number of years applicant has been in this business:

7. Person to contact for loss control survey:
   Phone #:

8. Check all that apply and add any others. Attach all brochures and promotional materials. Note that coverage will only apply to disclosed premises and operations.

   Do you perform the following services:

   Drop-off care facility Overnight care (see supplement)
   Sick Child Care (see supplement) Special needs care (see question #35) After school care
        (Percent of enrollment devoted to after school care: %)
   Temporary care at a shopping mall, convention hall, health club facility
        or other venue
   Special instruction (dance, gymnastics, music, etc.) indicate type(s): Other operations:

9. Do you carry Accident-Medical coverage?YES NO

   If yes, who is the insurance carrier for Accident Medical coverage?

10. Are employees (paid & volunteer) required to complete an employment application? YES NO

    If no, explain:

11. 1. Are criminal investigations conducted on all employees (paid & volunteer) before hiring? (This includes any parents who will be regular volunteers in the facility) YES NO
       

    2. Which of the following do you use to do background checks on your employees & volunteers?

       County criminal record search State criminal record search
       National criminal index search State prison search
       Federal prison search Sex offender search
       Criminal index search Nationwide U.S. Wants & Warrants search Teacher license Education verification FBI

12. Does your staff (paid and volunteer) employment application include questions about whether the individual has ever been convicted of any crime, including sex-related or child-abuse
    related offenses?YES NO
    

13. At staff orientation, do you discuss child abuse and sexual abuse, how to recognize the signs, and what to do if a child reports someone molested him/her? YES NO

    Do you require mandatory training for all employees each year about these subjects? YES NO
    

14. Do you verify employment references?YES NO

    Do you conduct a personal interview? YES NO
    

15. Have you had an incident which resulted in an allegation of sexual abuse? YES NO

    If yes, please describe details including any resulting claims, the outcome and damages paid.

16. Do you have a written policy addressing abuse and individual contact that may occur between children and volunteers or staff? YES NO
    

17. Do you have guidelines that prohibit the use of
    corporal punishment? YES NO
    

18. Do your rules and guidelines include listing all staff responsibilities for all activities including on and off-premises activities? YES NO
    

    Facility - LOCATION 1 (Complete an additional location supplement for each other location)

19. Do you operate more than one location? YES NO
    If yes, explain if it's not submitted to us to insure:

20. How long has applicant operated at this location?

21. Location address, if different than mailing address:

22. Is the facility licensed by the State? YES (Mail copy) NO
    If no, explain in Remarks Section.

23. Has the license ever been revoked? YES NO
    
    If yes, explain:

24. Hours of operation: From to
    Number of days per week:
    Number of months per year:

25. Child care facility located at: Private home Church Apartment YMCA Commercial Bldg. Other:

26. List other occupancies in the same building:

27. List adjacent businesses:

28. Additional Insured required? YES NO
    

    Name
    Address
    Relationship:

29. Name of Executive Director/Manager:
    Number of years in child care:
    Specialized training or education:

30. Number of teachers with degrees:
    Number of teachers without degrees:

31. Number of Aides: Number of Volunteers:
    Number of Nurses: Number of EMTs:

32. Number of Kitchen Staff: Number of Janitorial Staff:
    Other (describe position and number of employees):

33. Total number of employees:
    Any employees under 18 years of age? YES NO
    

    If yes, how many?

    List position and how they are supervised:

34. Is there always someone trained in CPR and first aid on the premises? YES NO
    

35. Licensed Capacity:
    Current Enrollment:
    Average Number of Children per day:

36. 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 (excluding director)?

    Infants, ages 0-1	# Staff	# Children
    Toddlers, ages 1-2	# Staff	# Children
    Toddlers, ages 2-3	# Staff	# Children
    Preschoolers, ages 3-5	# Staff	# Children
    School age children	# Staff	# Children
    	Total Staff	Total Children

37. Are "special needs" children cared for? YES NO
    
    1. If yes, how many?
       
    2. Is someone on your staff trained to care for
       these children? YES NO
       
    3. Is physical therapy provided? YES NO
       If yes, is it provided by a contracted professional who provides you with a certificate of insurance? YES NO
       
    4. Is an aide assigned to accompany the child? YES NO
       
    5. Describe the disabilities and special arrangements made to care for these children:

38. Does the facility have its own play area? YES NO
    If no, give name of play facility used:

    Does the playground you use meet all safety requirements of the CPSC (Consumer Products Safety Commission)? YES NO

39. Is play area fenced? YES NO
    List all playground equipment:

40. Please indicate type of surface under play equipment and depth in inches:

    Coarse Sand: "
    Double Shredded Mulch:"
    Engineered Wood Fibers:"
    Fine Gravel:"
    Fine Sand:"
    Medium Gravel:"
    Shredded Tires:"
    Wood Chips:"
    Other (type & depth):

41. Was equipment installed by, or has it been inspected by, someone certified in playground safety? YES NO

    How often are regular maintenance and routine inspections performed on the equipment? At least: Weekly Monthly Only as needed
    Other (Specify):

42. Does the center have playground equipment with a primary platform higher than 6 feet? YES NO

    Is there any play apparatus higher than 8 feet? YES NO
    If yes, describe:

43. Do you utilize swimming facilities? YES NO
    If yes, complete the Swimming Pool Supplement.

44. To prevent children from accessing cooking areas, stoves, microwave ovens, etc., please indicate which of the following precautions are taken:
    Separate kitchen with closed door Gate covering kitchen entrance area
    Other

45. To prevent children from being released to unauthorized persons, please indicate which of the following precautions are taken:
    Sign-out sheet
    Staff member must see the person before child is released
    Staff member calls parent when unfamiliar person comes
         to pick up child
    Staff member checks ID against child's "approved"
          pickup list before releasing child
    Other:

46. Please indicate which of the following procedures are used when dispensing medications to children:
    Written parental permission is required
    Written instructions for use is provided by the parent
    Medication is kept in its original container/package
    Written records are kept of all medications dispensed
    Other:

47. Are there any pets at this location? YES NO
    If yes, describe the pet, including size:

48. Are special classes provided (like music, dance, gymnastics, etc.)? YES NO

    If yes, explain.

    If special classes are taught by an independent contractor on your premises, do you require them to provide proof of liability coverage? YES NO

49. Do you warm baby bottles in an area not accessible
    to children?YES NO

50. Do you have a crisis management plan for dealing with participants, employees, children, parents, authorities, and media in the event of an abuse allegation or incident or other type of crisis? YES NO
    

51. Does the facility have an emergency evacuation plan posted and is it practiced? YES NO

52. Does the facility have video cameras installed to monitor all daily activities? YES NO

53. Number of field trips conducted each year:
    1. Is an attempt made to obtain release forms from both parents/guardians for each trip whenever possible? YES NO
       
    2. Are any trips overnight? YES NO
       
    3. Are staff to child ratios maintained or increased for trips? YES NO
       
    4. Are all children required to wear an identification badge? YES NO
       
    5. Describe types of field trips:

54. Do you sponsor any special events or fund-
    raising activities? YES NO
    If yes:
    1. If Yes: For each event, list the following: Type of event, number of participants, planned activities, expected revenue, length of time, whether or not liquor is served and if you obtain Certificates of Insurance from all vendors.

    2. Do you rent facility to others? YES NO
       If so, to whom and for what purpose?

    3. Do you obtain Certificates of Insurance from them? YES NO

55. Does the facility provide transportation to and
    from the center? YES NO

56. Does the facility provide transportation for field trips? YES NO
    If yes, on average, how far from the facility are the field trips?

    If no, indicate how transportation is provided:
    Vans are rented with drivers
    Vans are rented without drivers
    Buses are rented with drivers
    Buses are rented without drivers
    Parents, staff and volunteers drive their own cars
    Other:

57. After vacating the vehicle, is a final check made after every use to make sure nobody is left inside? YES NO

58. Are all drivers at least 21 years of age? YES NO

    Do you obtain MVRs on all drivers? YES NO

59. Do all drivers of applicable vehicles have a CDL license in accordance with state regulations? YES NO

60. Do employees/volunteers transport children in their own vehicles? YES NO
    If yes, how often:

61. Total number of owned vehicles:
    Total number of hired vehicles:
    Annual cost of hire:$

62. Are Certificates of Insurance required:
    
    1. From drivers of personal vehicles showing auto liability limits of at least $300,000? YES No
       
    2. From drivers of hired vehicles showing liability limits equal to or greater than the insured's limits? YES NO

63. Numbers of students by age: Under 7 years old Over 7 years old

64. Plan Desired:
         Plan A - $12,500 Accident Medical Expense,
                         $10,000 Accidental Death & Dismemberment, $0 Deductible
         Plan B - $20,000 Accident Medical Expense,
                         $10,000 Accidental Death & Dismemberment, $0 Deductible

65. Has any prior coverage been cancelled or non-renewed? YES NO

    If yes, explain:

66. Prior Policy Information

    
    

    Policy Type	Company	Effective Date	Limit	Total Premium
    Accident Medical
    General Liability
    Property
    Auto
    Other

Enter all claims or occurrences that may give rise to claims for the prior 5 years;

None:

Date of Occurrence	Line of Insurance	Type/Description of Occurrence or Claim	Date of Claim	Amount Paid	Amount Reserved	Claim Status

Selection Claim Status: O = Open, C =Closed