Name of Business:
Your Name:
Address:
City:
County:
State:
Zip:
Phone:
E-mail:
Fax:
1. Our Day Care Center is:



2. How long has the center been in business?
3. In the past 12 months, have any complaints been filed with the Licensing Board against your facility?



If yes, please explain:
4. In the last 3 years have any of your licenses been revoked, suspended or placed under probation?



If yes, please explain:

5. How many children are you licensed to care for?

Loc#1 Loc#2

Additional Locations:

6. What are the center's hours of operations? to

If more than 12 hours a day, how many hours total:

7. Do you perform a criminal background investigation, including sexual abuse or child abuse related offenses on prospective employees?



If yes, how often?
8. Do you perform a criminal background investigation, including sexual abuse or child abuse related offenses on prospective volunteers?



If yes, how often?
9. Do you have a Student Accident Insurance Policy in effect?



10. Are there any other business operations at these locations?



What date would you like for coverage to be effective?
General Liability Limits:
If you have any employees or volunteers, please complete all of the following questions. If you are the only employee, please move on to Step 3.
1. Indicate the number of employees:

Full-time

Part-time

2. Indicate the number of volunteers:

Full-time

Part-time

3. Has there ever been an allegation of sexual abuse made against an employee or volunteer?



1. Is the center located in a :






2. If located in a private home, provide the name of the homeowner's insurance company:
3. If located in a commercial building:
A. Are there any other occupants in this building?



B. Do you own the building?



C. Do you lease any space to other tenants?


If yes, what is the square footage of the area leased to others?
D. Are any residential apartments located within this building?



1. Do you provide any transportation of children or parents?

If yes, please answer the following:
A. Do you transport children in:





B. What is the youngest age of any driver:
C. Do you have a "Commercial Auto" policy?



1. Do you provide any on premises or off premises water activities?


If yes, answer the following questions:
A. Describe any water activities on the premises:




B. If there is a pool or wading pool, is it fenced?



C. Is there a diving board?




D. Is there a slide for the pool or wading pool?



E. Is any employee certified as a lifeguard or in water safety?



F. Are children allowed to participate in off-premises water activities?



G. Is written permission obtained from parents for any water activities?



If yes, please describe
1. Is there a trampoline on the premises?



2. Is there any gymnastic equipment on the premises?



If yes, please describe:
3. Are there any dogs on the premises?



If yes, please list the breed and any previous biting history:
4. Are there any other pets or animals on the premises?



If yes, please describe:
5. Are the children allowed contact with any animals?



If yes, please describe:
Check the box next to the optional coverage(s) you would like us to include in your quote.
Employee Benefits Liability
ie. coverage in case you fail to correctly insure an employee under your group benefits plan.
Employment Practices Liability
ie. protection for suit brought by an employee for wrongful termination, discrimination for age, ace, gender, disability etc.
1. What is the total annual payroll for all employees?
2. Have you had any workers compensation losses in the last 4 years?



If yes, please explain:
Additional Comments/Questions: (Limit of 200 words)
Please scroll back to the top and double check that
you have completed all the fields necessary before
submitting this form.
How would you like to be contacted?




© 2007 Newaygo Insurance Agency, Inc.