• Child Care Insurance Questionnaire

    In-Home Child Care Ineligible
  • Applicant is:

  • GENERAL QUESTIONS

  • 1. Is the center (In-home ineligible):

  • 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
  • 3. In the past 12 months, have any complaints been filed with the Licensing Board against applicant’s facility?
  • 4. In the past 3 years has any of the applicant’s licenses been revoked, suspended or placed under probation?
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  • 6. Is applicant licensed/certified for: (In-home, Grades 1–12 & home schools are not eligible)
  • 8. Are the door hinges protected with hinge guards?

  • STUDENT ACCIDENT INSURANCE

  • 1. Do you need Student Accident Insurance?

  • EMPLOYEE OPERATIONS

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  • ABUSE & MOLESTATION

    Please provide copies of any and all polices and procedures in place to prevent/avoid physical or sexual abuse and sexual misconduct/molestation.

     

  • 1. Has there ever been an allegation of physical or sexual abuse or sexual molestation made against the insured or its members?
  • 2. Does the applicant have knowledge of any incident which could give rise to, or result in, an allegation of physical or sexual abuse or sexual molestation?
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  • 10. Do you allow your employees, volunteers and/or independent contractors to be alone, one on one with clients
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  • 11. Is there a written policy prohibiting 1:1 interactions with minors?
  • 13. Does the applicant have supervision plans that monitor relationships and interactions between clients / children and other clients / children? (Examples: overnight accommodations, restrooms, locker rooms, etc.)?

  • OTHER OCCUPANCIES

  • 1. Is the center located in:
  • 1b. If located in a commercial building, are there any other occupants in this building?
  • 2. Does the applicant own the building?
  • 2a. Does the insured lease any space to other tenants?
  • 2b. Are any residential apartments located within this building? (Attach copy of tenant's HO4 & Lease Agreement.)

  • WATER ACTIVITIES

  • 1. Does the applicant provide any on or off premises water activities?
  • 1a. Describe any water activities on the premises:
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  • OTHER ACTIVITIES

  • 1. Is there a trampoline on the premises?
  • 2. Is there any gymnastic equipment on the premises?
  • 3. Are there any dogs on the premises?
  • 4. Are there any other pets or animals on the premises?
  • 5. Are the children allowed contact with any animals?

  • OTHER LIABILITY COVERAGE

    Check "Yes" if you would like us ot incude the following coverage in our quote. Check "No" if you do not want the coverage.

  • 1a. Abuse & Molestation Coverage - Optional in some states

  • Optional coverage is available for Physical or Sexual Abuse or Sexual Molestation excluding the
    perpetrator. Multiple incidents to one person shall be deemed to be one occurrence and subject
    to coverage limits in effect at the time of the first incident. Prior to providing coverage, Childcare
    operators must conduct personal background checks on all employees and volunteers (and all
    residents 18 and older for in-home operations) or have signed affidavits as required by state
    statue. Background checks must be done regularly & maintained in file for all current & past
    employees and volunteers including in-home residents (18 and older).

  • 1b. Do & Cat Liability Coverage (in-home centers only)

  • This endorsement provides a Limit of liability for bodily injury or property damage arising out of the insured's ownership, care, custody and control of any dog and/or cat. It is only available for in-home operations. (Damages arising o ut of the insured's ownership, or care, custody, or control of any dog and/or cat are otherwise excluded from coverage).

  • 1c. Hired & Non-Owned Auto Liability

  • Hired Auto Liability covers bodily injury and property damage arising out of the maintenance or
    use of a hired auto by you or your employees in the course of your business. Hired auto means
    any auto you lease, hire, rent, or borrow. Non-Owned Liability covers bodily injury and property
    damage arising out of the use of any non-owned auto in your business, by any person other than
    you, in the course of your business. Non-owned auto means any auto you do not own, lease, hire, rent, or borrow which is used in connection with your business. (Available only if we provide coverage for vehicles.)

  • 1d. Water Activities
  • What type?

  • This is an optional coverage to pay for bodily injury claims that arise out of the use, ownership, or maintenance of any body of water or pool whether the childcare water activities are on or off
    premises.

  • 1e. Water Activities On & Off Premises – Policy Limit

  • The limit of liability for water activities is the same as, and included within the General Liability
    policy limit. This is an optional coverage to pay for bodily injury claims that arise out of the use,
    ownership, or maintenance of any body of water or pool whether the childcare water activities are on or off premises. (Certified lifeguard is required on premises for policy limits).

  • 1f.Roll-on Employment Practices Liability Insurance (EPLI) Coverage (Only available if 19 or fewer employees)
  • EPLI

  • Coverage for any actual or alleged act of discrimination, harassment, wrongful discipline, and many other employee related practices that you become legally obligated to pay

  • 1g. Employee Benefits Liability

  • This is an optional coverage to pay for damages that are caused by any negligent act, error, or omission by you or any other person in connection with the administration of your "employee benefits program".

  • PROPERTY INSURANCE

  • 1. Do you need Building and/or Content Coverage?
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  • 1b. Property Deductible
  • 2. Do you need Equipment Coverage?
  • 2a. If yes, total value to insure for?
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  • TRANSPORTATION & COMMERCIAL AUTOMOBILE INSURANCE

     

  • 1. Does the applicant provide any transportation of registrants? If yes, please answer the following:
  • 1a. Do you transport children in:
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  • 1d. Do you have a Commercial Auto policy?
  • 2. Does the business title any automobiles or other operating vehicles in the business name?
  • 3. Is insurance coverage needed for owned automobiles?
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  • COMMERCIAL CRIME

     

  • 1. Do you desire coverage for Crime (Employee Dishonesty, Money, Forgery)?

  • COMMERCIAL UMBRELLA

  • 1. Do you need a Commercial Umbrella?

  • DIRECTORS AND OFFICERS INSURANCE

  • 1. Do you need Directors and Officers Liability Coverage? (If yes, please contact Kevin Morency.)

  • WORKERS' COMPENSATION INSURANCE

  • 2. Do you need Workers Compensation? (If yes, please contact Kevin Morency.)

  • SIGNATURE

  • The information I have provided is true and accurate to the best of my knowledge. I have not willfully concealed or misrepresented any material fact(s) or information. I understand completion of this questionnaire does not compel the company to provide coverage.

  • Questions? 877-244-9090
    Kevin Morency |  kmorency@morencyinsurance.com 

    Morency & Associates Inc.
    141 New Shackle Island Rd, Hendersonville, TN 37075
    Fax: 615-452-6580

    https://insurancechildcare.com/

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