DAYCARE APPLICATION

Name of Applicant:

Mailing Address:

Applicant is:IndividualPartnershipCorporationOther:

Policy Period:FromTo

Limits:General Aggregate Each Occurrence

Products-Completed OpsIncluded in General Agg.Damage To Premises Rented To You

Personal & Advertising Injury Medical Expense

PLEASE ANSWER ALL QUESTIONS COMPLETELY.

1.Location of property to be insured (If more than one location attach separate sheet):

2.Years in business? Prior years experience in this type of work?

How long in business at this location?

3.Daycare facility located in:Commercial Bldg.ChurchHomeOther

4.Owner Occupied:Tenant Occupied:

5.Additional Insureds:

If yes, explain:

6.Area (sq. ft.): Total:Insured occupies% of Total

7.Is risk licensed by State? ...... Yes No

State License No.: Expiration Date:

8.Number of children licensed: Number enrolled:

Hours of Operation: Number of days open:

9.Any physically or mentally disabled or other “special” children?...... Yes No

Number: Explain:

10.Indicate number of children in each age group and the number of attendants assigned to each age group:

AGE GROUP / NO. OF CHILDREN / NO. OF ATTENDANTS
Under 2 Yrs.
2 Yrs.-3 Yrs.
4 Yrs.-5 Yrs.
6 Yrs.-8 Yrs.
9 Yrs.-Over

11.Number of Employee/Assistants:Full-Time Part-Time

12.Does Insured have immediately available transportation for Medical Emergency? ...... Yes No

Type:

13.Do they dispense medication? ...... Yes No

If yes, are written instructions provided? ...... Yes No

14.Is staff trained in CPR? ...... Yes No

Is staff trained in First Aid?...... Yes No

If yes, describe training:

15.Has any of your staff, including yourself, been implicated, arrested or convicted of any crime other than a traffic violation? Yes No

If yes, explain, including name, dates and circumstances of each occurrence:

16.a.Are there any nurses or health care professionals?...... Yes No

b.Do any children stay over night?...... Yes No

c.Is any weekend or holiday care provided?...... Yes No

d.Does risk accept drop-in children?...... Yes No

e.Is the facility involved in any way with state, federal or county Social Services Agenciesor receive any direct funding? Yes No

Explain any yes answers:

17.Is there a kitchen area?...... Yes No

Children allowed in kitchen?...... Yes No

18.Number of Fire Exits:

19.Indicate types of Fire Extinguishers on premises: Soda AcidC02Dry Chemical

Have all extinguishers been checked within the last year?...... Yes No

What Safety Equipment is on premises:

Smoke DetectorsSprinklersFire Alarm

Exit Signs Child Safety EquipmentElectrical Outlet Safety Plugs

Other:

20.Does risk have a playground?...... Yes No

Fenced?...... Yes No

Size of Yard/Play Area:

21.Does the Play Yard have Swimming Facilities? ...... Yes No

PlasticAbove GroundBelow GroundDepth of Waterft. Height

Fenced? ...... Yes No

Self Locking Gate? ...... Yes No

22.Is there any off premises water hazard? ...... Yes No

If yes, explain:

Does Insured/Employee supervise all children during water play? ...... Yes No

23.Any special classes taught (i.e., gymnastics, dance or regular athletic activities)? ...... Yes No

If yes, explain:

24.Any field trips or activities conducted away from premises?...... Yes No

If yes, how many?

Where?

Mode of Transportation:

25.Are there any pets at this location?...... Yes No

If yes, explain:
26.What floors, other than ground levels, are open to children and for what use:

27.Condition of stairways (if applicable):GoodFairPoorNone

Is stairway well lighted? ...... Yes No

Is stairway equipped with slip resistant treads? ...... Yes No

28.What are the safety procedures in the event of fire?

29.Does Insured provide any safety education for children? ...... Yes No

If yes, describe:

30.Do you have an accident/health policy?...... Yes No

Is coverage mandatory for all students?...... Yes No

Provide carrier and limits:

Policy term: to......

PRIOR CARRIER INFORMATION
Year: / Year: / Year: / Year: / Year:
Carrier
Policy Number
Total Premium
LOSS HISTORY—FIVE YEAR PERIOD
Indicate all claims or losses (regardless of fault and whether or not insured) or occurrences that may give rise to claims for the prior five years.
Date of
Loss / Description of Loss / Amount Paid / Amount
Reserved / Claim Status (Open or Closed)

This application does not bind the applicant nor the Company to complete the insurance, but it is agreed that the information contained herein shall be the basis of the contract should a policy be issued.

APPLICABLE IN THE STATE OF NEW YORK:

Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.

FRAUD WARNING (APPLICABLE IN TENNESSEE AND WASHINGTON):

It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits.

FRAUD WARNING:

Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.

APPLICANT’S SIGNATURE: DATE:

AGENT NAME: AGENT LICENSE NUMBER:

(Applicable to Florida Agents Only.)

NAME AND PHONE NUMBER OF INDIVIDUAL TO CONTACT FOR INSPECTION/AUDIT:

IMPORTANT NOTICE
As part of our underwriting procedure, a routine inquiry may be made to obtain applicable information concerning
character, general reputation, personal characteristics and mode of living. Upon written request, additional
information as to the nature and scope of the report, if one is made, will be provided.

ANSWER ALL QUESTIONS—IF THEY DO NOT APPLY, INDICATE “NOT APPLICABLE”

WHI APP-141 (08-07)Page 1 of 4