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COMMERCIAL & RESIDENTIAL CHILDCARE CENTER QUOTE
Applicant's Name:
Mailing Address:
City  State     Zip
Phone:      Fax: 		PROPOSED EFFECTIVE DATE:
From     To

Email:

SECTIONS      GL       Property       EPLI       Umbrella

 Insured Contact:
 Location Address:      City/State/Zip:

 Years in Business

 Business Entity: Individual    Partnership    Corporation     NonProfit Organization

 Where is the business located? Commercial Building      Private Residence

 Submit details of any losses in the past 5 years:   
 COMMERCIAL GENERAL LIABILITY
 1. Limits of Liability Requested:
     General Liability:
      100/100   100/300   300/300    300/600   500/500   500/1Mil   1Mil/1Mil   1Mil/2Mil
     Molestation & Abuse:
     25/25   100/100   100/300    300/300   300/600   500/500   500/1Mil   1Mil/1Mil

     Non-owned Auto Liability      Hired/Non-owned Auto Liability

 2. Morning Enrollment      Afternoon Enrollment      Number of Employees
 
 3. License Capacity
 
 4. Defense Cost Coverage Yes    No
 
 5. For building owners only:
     Number of Apartments units
     Square foot rented to others (other than apartments) sq. ft.    Occupancy
 
 6. Number of wading pools     Number of swimming pools

 
7. Do any of the following exposures exist?
Eligible
Submit
Prohibited
    Any Animals/Pets other than dogs or cats?
No
Yes
  
    Is this a 24 hr. operations or overnight care?
No
 
Yes
 
 
    Over 52 Field Trips per year?
No
Yes
 
 
 
    Any trampolines or gymnastics equipment?
No
 
Yes
 
 
    Any handicapped or retarded children?
No
Yes
 
 
 
    Any employed or contracted physicians or nurses?
No
Yes
 
 
 
    Applicant is required to be licensed and is not?
No
  
Yes
 
 
    Has there been a suspension or revocation of certificate or license?
No
Yes
 
 
 
    Any alleged or actual incidents regarding child molestation or abuse?
No
Yes
 
 
 
    Are background checks done on all potential employees?
No
Yes
 
 
 

 
 
Yes
No
8. Is facility open more than 14 hours per day?
9. Does the applicant have a swimming pool? (Must be fenced)
    If Yes, is the pool used by the children? (Decline if, diving board or slide)
10. Does the applicant have a dog or cat?
      (Submit aggressive dogs Breed )
11. Does the facility allow children to be dropped off that are not enrolled in the program?
12. Are field trips taken?
      If yes,       1-12 per year       13-51 per year
13. Is an Accident and Health policy for the children in force?
      If Yes, Advise limits       $2,000       $3,000        $5,000       $10,000
14. List any additional insureds and their interest:   

COMMERCIAL PROPERTY
1. Is property prohibited in our Coastal Guidelines?     Yes    No
    Cause of Loss    Basic      Special
    Property deductible    500       1,000     2,500       5,000
2. Building Construction   Protection Class    Area Sq. Ft.

3. Coverage Desired
Limit
 
    Building
RC     ACV
    Bus. Personal Property
RC     ACV
    Business Income

Building & Business Personal Property Coinsurance: 80     90     100
4. Optional Coverages (Where available)
    Property enhancement endorsement Yes     No
    Glass Coverage linear feet
    Employee Dishonesty 5,000     10,000    25,000     50,000 100,000
    Money & Securities    1,000     2,000      5,000

5. List any loss payees or mortgagees to be added:   

EMPLOYMENT PRACTICES LIABILITY
 1. Total Number of Employees: Full Time + (Part-time x .5) = Total
2. Has there been a reduction of employees in last 12 months? Yes    No    Percentage
3. Has the Organization closed any facilities, downsized, sold, laid off, or reduced staff, or merged or acquired any company in the
    past 12 months or does the Organization plan to do so in the next 12 months?    Yes    No
4. Within the last 5 years has any employment related or third party discrimination, or third party sexual harassment: inquiry,
    complaint, notice of hearing, claim or suit been made against the Organization or any person proposed for Insurance in the
    capacity of either Director, Officer or Employee of the Organization?    Yes    No
5. Is any person proposed for this Insurance aware of any fact, circumstance or situation which may result in an employment claim
    or third party discrimination or third party sexual harassment claim against the Organization or any of its Directors, Officers, or
    Employees?     Yes    No

COMMERCIAL UMBRELLA:   Desired Limit
To include Automobile, the underlying Limit ust be $1,000,000, GL Limits must be at least $500,000
1. Have there been any Auto losses greater than $10,000 in the past 5 years?
2. Are there more than 8 vehicles?
3. Is Molestation coverage required?

4. Auto Liability Carrier
    Limits     Premium 		WC or Employers Liability Carrier
Employers Liability Limits

 
Vehicles (describe) :   

 
Additional Information:   


 

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