Enrollment:

Insurance coverage for your child care business will begin upon receipt and approval of your program application, membership application, and payment, or a start date that you specify, whichever is later.

The policy starts and ends each calendar year on September 1st. Individuals may apply for membership benefits at any time during the policy period. It is not necessary to wait until the policy renews each year on September 1st. Please note that premiums and membership fees are "minimum" and may not be prorated.

Enroll by Mail/Fax:

Complete the Family/Group Family Child Care Program Application and the CHILD, Inc. Membership Application/ Agreement: English | Español
If Applicable, Complete Pool Disclaimer: English
Mail or fax applications and a copy of your child care license
Mail your payment (check/money order payable to CHILD, Inc.)

Mailing Address:

CHILD, Inc.
PO Box 222
Weatogue, CT 06089-0063

Fax Number:

(860) 844-8274

CHILD, Inc. Membership Application/Agreement

PLEASE NOTE: Completion of the Membership Application/Agreement is MANDATORY.

The following form is for online enrollment into the CHILD, Inc. program. If you would prefer to enroll by mail/fax please refer to the instructions listed on the left panel of this page. Thank you. Required fields are in RED.

Provider Name:

Business Name:

Address:

City: State: Zip:

Home Phone: Fax Phone:

Email:

Please enter here any persons, landlords, or organizations that you are contractually obligated to name as "Additional Insured" on the policy for your child care business:

OPTION 1: $1,000,000 per occurrence liability limit/$3,000,000 liability policy limit $20,000 accident medical expense/$10,000 accidental death & dismemberment

# of Children	Premium*	Premium after March 1, 2012*
1-9	$494	$262
10-12	$698	$364
13-17	$968	$499

OPTION 2: $100,000 per occurrence liability limit/$300,000 liability policy limit $20,000 accident medical expense/$10,000 accidental death & dismemberment

# of Children	Premium*	Premium after March 1, 2012*
1-9	$368	$199
10-12	$512	$271
13-17	$704	$367

*Premium already includes $30 membership fee. Do not send any additional money.

Total Amount Enclosed $

Please Choose Payment Method: Online with Paypal or Mail Check

CHILD, Inc. Membership Agreement

Please accept my child care business as a CHILD, Inc. member from date of application to September 1st. I will keep CHILD, Inc. informed, at all times, of any substantial changes in my child care operation. Further, it is understood that no coverage of any kind under CHILD, Inc. exists prior to receipt of this application and once CHILD, Inc. has remitted fees to the insurers, they are non-refundable.

Signature of Child Care Provider: Date: