Applicant’s Name:
Business Name:
Mailing Address:
City: State: CA CT DE IA IL IN KS MA MD ME MI MN NH NY OH OR PA RI VT WA Zip:
Street Address (if different):
City: State: CA CT DE IA IL IN KS MA MD ME MI MN NH NY OH OR PA RI VT WA Zip:
Phone Number:
E-mail address:
How did you hear of us?

1. Child Care License Number License Expiration Date
2. What is the maximum number of children your license/registration allows to be in your care?
3. What is the maximum number of children in your care at any one time?
4. What is the number and ages of children who live with you?
5. Number of years experience in child care for the following:
   You ( years), your assistants ( years) and your substitute(s) ( years).
6. List all specialized training and/or education for the following:
   You
   Your assistant(s)
   Your substitute(s)
   Does all training meet state requirements? YES NO
7. List memberships in any child care associations or other programs relating to caring for children

8. Child care operates in which of the following?
   Single family dwelling Multiple family dwelling Apartment (which floor? )
9. Is there a fire extinguisher in the home? YES NO
10. How many smoke alarms are there?
    Is there at least one on every floor (if multiple stories)? YES NO N/A
11. Describe all playground equipment and the maximum height of each item:
12. How is the play area protected? Fence (Height )
    or Natural boundaries (Describe type of boundary and the Height)
13. Do you have a swimming pool, either above or below ground? YES NO
14. Do you have a trampoline? YES NO
15. Is smoking permitted in areas with children? YES NO

16. For state licensing/registration requirements, please indicate who has had criminal background checks.
    Yourself Your assistants Your substitutes Anyone in your household over the age of 16
17. Do you obtain a physician's statement that qualifies you and all members of your household as medically acceptable to provide child care services? YES NO
18. Is the licensed child care provider under the age of 18? YES NO
19. Are assistants under the age of 18 supervised at all times? YES NO N/A
    If no, explain situations where they would watch children without supervision
    
20. Are infants under one year old allowed to sleep on their stomachs? YES NO N/A
    If yes, is a physician's written permission obtained for each infant? YES NO
21. Are fire drills conducted in accordance with state guidelines? YES NO
22. Is there a first aid kit in your home? YES NO
23. Do you keep emergency phone numbers for both parents and the children's physicians? YES NO
    If no to either question, explain
    
    Do you keep the numbers updated? YES NO
24. Do you have pets? YES NO
    If yes, please describe the pets and breeds and how you keep them separated from the children.
    
25. Do you have someone you can use as a back-up caregiver in the event of an emergency? YES NO
26. Is someone trained in CPR/First Aid on the premises at all times? YES NO
27. Do you and your staff know how to recognize the signs of abuse, both physical or sexual, and what to do if a child reports someone has abused or molested him or her? YES NO
28. How many field trips do you take monthly?
    Describe types of trips:
    

For any “Yes” answer to the following questions, details must be fully explained in the Comments section.

29. Do you care for any mentally, emotionally or physically challenged children? YES NO
    If yes, please provide details, including the types and extents of the conditions and any special arrangements you’ve made for their care.
    
30. Do you give medicine to children? YES NO
    If yes, are they dispensed in accordance with state guidelines? YES NO
31. Do any children stay overnight? YES NO
    If yes, provide details, including frequency and circumstances.
    
32. Is any weekend care provided? YES NO
    If yes, provide details, including frequency and circumstances.
    
33. Has your license or registration ever been suspended or revoked? YES NO
    If yes, provide details and circumstances.
    
34. Have you ever had an incident which resulted in an allegation of sexual abuse? YES NO
    If yes: Was an insurance claim made? YES NO
    Was the case settled? YES NO N/A
    Was the case taken to trial? YES NO N/A
    What damage amounts were paid, either from settlement or trial? $
    Please explain details and circumstances about the incident and/or claim.
    
35. Has there ever been a claim or suit brought against you or your insurance company for any reason?
    YES NO
    If yes, explain in detail, including amounts paid or reserved.
    
36. Are you aware of any fact, circumstance, situation or event which might lead to a claim or suit against you?
    YES NO
    If yes, explain in detail.
    
37. Has your insurance ever been cancelled or declined? YES NO
    If yes, explain in detail.
    

Please read and sign the following sections:

IN ADDITION TO COMMON POLICY EXCLUSIONS, THERE ARE ADDITIONAL EXCLUSIONS THAT ATTACH TO THE POLICY. The CHILD, Inc. Liability policy underwritten by Markel Insurance Company does NOT provide any coverage for claims, damages and expenses arising out of the following: Swimming Pools, Pets of any kind, Trampolines, Automobiles, Lead, Asbestos, Employment Related Practices, Mold, Terrorism, War, Pollution, Electronic Date Recognition Problems, Punitive Damages and any operations or businesses other than Child Care. YOU MAY OBTAIN A COMPLETE COPY OF THE MASTER POLICY UPON WRITTEN REQUEST.

I have read and understand the above paragraphs regarding the exclusions that apply to my Child Care business.

Applicant’s Signature: Date:

Coverage shall not be bound until the Company approves the applicant’s completed application and premium payment is received. The Company’s receipt of premium does not bind coverage until the completed application is also approved. In the event the Company does not approve your application, your premium payment will be refunded.

Fair Credit Report Act Notice: An investigative consumer report may be requested by the insurer to which this application is assigned as to the consumer’s character, general reputation, personal characteristics and mode of living. Subsequent consumer reports may be requested in connection with an update or renewal, or extension of the insurance for which this application is made. The applicant will be informed of the name and address of the consumer-reporting agency that furnished the report.

Fraud Warning: Any person who knowingly and with intent to defraud any insurance company or other person, files an application for insurance 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 the person to criminal and [NY residents: substantial] civil penalties. In Maine insurance benefits may also be denied.

I hereby certify that to the best of my knowledge and belief the information provided is true and correct and that no information which would materially affect this insurance has been withheld.

Applicant’s Signature: Date: