Child Care Insurance Questionnaire

Child Care Insurance Questionnaire

In-Home Child Care Ineligible
Applicant's Name:*
Address:*
Mailing Address
Address (cont):*
Mailing Address - continued
Contact:*
Email*
Telephone:*
Website
Fax:
Applicant is:

IndividualPartnershipCorporationOther (specify)Other
Current Carrier:
Expiration Date:
Limits: ($)
Premium: ($)
Deductible: ($)
GENERAL QUESTIONS
1. Is the center (In-home ineligible):

LicensedCertifiedRegistered (Iowa)None
Note: Center MUST be licensed or certified to be considered for coverage (or "Registered" for Iowa only. (Attach copy of state license.)
1a. Limits Desired

$300,000 per occurrence / $600,000 aggregate$500,000 per occurrence / $1,000,0000 aggregate$1,000,000 per occurrence / $2,000,000 aggregate
2. How long has the center been in business?
2a. if a new venture, please describe past experience.
3. In the past 12 months, have any complaints been filed with the Licensing Board against applicant’s facility?

YesNo
3a. If yes, please explain & provide documentation.
4. In the past 3 years has any of the applicant’s licenses been revoked, suspended or placed under probation?

YesNo
4a. If yes, please explain & provide documentation.

5. How many children is the application licensed to care for?

	Location 1	Location 2	Location 3	Location 4
Number of Children

5a. List locations below if different from applicant address above.
Location # - Street Address, City, State, Zip Code
5b. States in which the operation does business.
6. Is applicant licensed/certified for: (In-home, Grades 1–12 & home schools are not eligible)

Infant Care24 Hour CareSick Child CareBefore/After School CareK4/K5Other
6a. If you offer infant care, what method(s) do you use to warm bottles?
7. What are the center’s hours of operations?
8. Are the door hinges protected with hinge guards?

YesNo
STUDENT ACCIDENT INSURANCE
1. Do you need Student Accident Insurance?

YesNo
If no, please provide insurance company name, limits, and premium currently paying:
1a. What is the age range of your students?
1b. Number of students
1c. Limit desired

	Full-Time	Part-Time
Number of Employees
Number of Volunteers

	Yes	No
1a. On prospective employees and volunteers?
1b. On existing employees and volunteers?
1c. On all residents 18-years and older (for in-home centers only)?

	Yes	No
4a. Physical or Sexual Abuse or Sexual Molestation
4b. How to recognize the signs of abuse
4c. What to do if an individual reports someone molested them

	Yes	No	N/A
1b. If there is a pool or wading pool, is it fenced?
1c. Is there a diving board?
1d. Is there a slide?
1e. Is there a certified life-guard on staff at the premise where the water activities are held?
1f. Are children allowed to participate in off-premises water activities? (If yes, explain below at 1fi.)
1g. Is written permission obtained from parents for any water activities? (If yes, explain below at 1gi.)

	Building Age	Building Construction	Building Limit ($)	Content Limit ($)
Building 1
Building 2