Family/Group Family Child Care Program Application

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.

Select Your Liability Limits

CLICK HERE to preview ALL premium amounts (click again to hide), then select your liability limits below.

Please select one of the following Liability Limits:
$1,000,000 per occurrence/$3,000,000 aggregate (Policy Limit)
$100,000 per occurrence/$300,000 aggregate (Policy Limit)

Contact Information

Applicant�s Name:
Business Name:
Form of Business: Individual LLC Corporation Partnership Other
Mailing Address:
City: State: Zip:
Street Address (if different):
City: State: Zip:
Do you operate additional child care programs at other locations? YES NO
If yes, explain:

Phone Number:
E-mail address:
How did you hear of us?


Every question must be completed in its entirety. Please indicate �N/A� beside anything that does not apply to you or your child care operation.

Section 1 - General Information
  1. Child Care License Number License Expiration Date
  2. What is the maximum number of children your license/registration allows to be in your care?
  3. What is the maximum number of children in your care at any one time?
  4. What is the number and ages of children who live with you?
  5. List number of years experience, all specialized training and/or education for the following:
    You
    Your assistant(s)
    Your substitute(s)
    Does all training meet state requirements? YES NO
  6. List memberships in any child care associations or other programs relating to caring for children
Section 2 - Facility
  1. Child care operates in which of the following?
    Single family dwelling Multiple family dwelling Apartment (which floor? ) Other
  2. Do you live on the premises where the child care is located? YES NO
    If no, please explain:
  3. Describe all playground equipment and the maximum height of each item:
    How is the play area protected? Fence (Height ) or Natural boundaries
    Describe type of boundary and the height:
  4. Do you have a swimming pool, either above or below ground? Note that no liability coverage applies.
    YES NO
  5. Do you have a trampoline? Note that no liability coverage applies. YES NO
  6. Do you accept boarders in your home? YES NO
Section 3 - Operations
  1. For state licensing/registration requirements, please indicate who has had criminal background checks.
    You Your assistants Your substitutes
    Anyone in your household over the age of 16 Other
  2. Do you have any assistants under the age of 18? YES NO
    If yes, explain any situations where they would watch children without supervision:
  3. Are infants under one year old allowed to sleep on their stomachs? YES NO N/A
    If yes, is a physician's written permission obtained for each infant? YES NO
  4. Are fire drills conducted in accordance with state guidelines? YES NO
  5. Do you have first aid kits, smoke detectors and fire extinguishers? YES NO
    If no, explain:
  6. Do you keep emergency phone numbers for both parents and the children's physicians? YES NO
    If no to either question, explain

    Do you keep the numbers updated? YES NO
  7. Do you have pets? Note that no liability coverage applies. YES NO
    If yes, please describe the pets and breeds and how you keep them separated from the children.
  8. Do you have someone you can use as a back-up caregiver in the event of an emergency? YES NO
  9. Is someone trained in CPR/First Aid on the premises at all times? YES NO
  10. How many field trips do you take monthly?
    Describe types of trips:

For any �Yes� answer to the following questions, details must be fully explained.

  1. Do you care for any mentally, emotionally or physically challenged children? YES NO
    If yes, please provide details, including the types and extents of the conditions and any special arrangements you�ve made for their care.
  2. Do you give medicine to children? YES NO
    If yes, are they dispensed in accordance with state guidelines? YES NO
  3. Do any children stay overnight? YES NO
    If yes, provide details, including frequency and circumstances.
  4. Is any weekend care provided? YES NO
    If yes, provide details, including frequency and circumstances.
  5. Has your license or registration ever been suspended or revoked? YES NO
    If yes, provide details and circumstances.
  6. Have you ever had an incident which resulted in an allegation of sexual abuse? YES NO
    If yes, please explain details and circumstances about the incident and/or claim.
  7. Has there ever been a claim or suit brought against you or your insurance company for any reason?
    YES NO
    If yes, explain in detail, including amounts paid or reserved.
  8. Are you aware of any fact, circumstance, situation or event which might lead to a claim or suit against you?
    YES NO
    If yes, explain in detail.
  9. Has your insurance ever been cancelled or declined? YES NO
    If yes, explain in detail.
Section 4 - Additional Insured

The liability policy can provide Additional Insured coverage. Please list any persons or organizations that require this coverage.

Additional Insured Type:
Landlord Resource and Referral Agency Funding Source Other
Name of Person or Organization:
Address:

Additional Insured Type:
Landlord Resource and Referral Agency Funding Source Other
Name of Person or Organization:
Address:


Additional Comments:

Please read and sign the following sections:

Fraud Statements:

GENERAL STATEMENT Any person who knowingly and with intent to defraud any insurance company or another person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and subjects the person to criminal and [NY: substantial] civil penalties. (Not applicable in CO, DC, FL, HI, KS, MA, MN, NE, OH, OK, OR, VT or WA; in LA, ME, TN, and VA, insurance benefits may also be denied)

APPLICABLE IN COLORADO It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policy holder or claimant for the purpose of defrauding or attempting to defraud the policy holder or claimant with regard to a settlement of award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.

APPLICABLE IN KANSAS Any person who, knowingly and with intent to defraud, presents, causes to be presented or prepares with knowledge or belief that it will be presented to or by an insurer, purported insurer, broker or any agent thereof, any written statement as part of, or in support of, an application for the issuance of, or the rating of an insurance policy for personal or commercial insurance, or a claim for payment or other benefit pursuant to an insurance policy for commercial or personal insurance which such person knows to contain materially false information concerning any fact material thereto; or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act.

APPLICABLE IN MASSACHUSETTS, NEBRASKA, OREGON AND VERMONT Any person who knowingly and with intent to defraud any insurance company or another person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading information concerning any fact material thereto, may be committing a fraudulent insurance act, which may be a crime and may subject the person to criminal and civil penalties.

APPLICABLE IN MINNESOTA Any person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime.

APPLICABLE IN OHIO Any person who, with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deception statement is guilty of insurance fraud.

I understand that coverage shall not be bound until the Company approves the applicant's completed application and premium payment is received. The Company's receipt of premium does not bind coverage until the completed application is also approved. In the event the Company does not approve your application, your premium payment will be refunded.

I hereby certify that to the best of my knowledge and belief the information provided is true and correct and that no information which would materially affect this insurance has been withheld. All information in the application is deemed material to the underwriting and acceptance of risk.

Applicant�s Signature: Date:

 

IN ADDITION TO COMMON POLICY EXCLUSIONS, THERE ARE ADDITIONAL EXCLUSIONS THAT ATTACH TO THE POLICY.

I UNDERSTAND AND ACKNOWLEDGE THAT THERE IS NO COVERAGE FOR SITUATIONS INVOLVING SWIMMING POOLS, ANIMALS, TRAMPOLINES, MOLD, SILICA/DUST, LEAD, ASBESTOS, TRANSPORTATION, AND EMPLOYMENT RELATED PRACTICES. THIS POLICY DOES NOT PROVIDE ANY COVERAGE FOR ANY OPERATONS OTHER THAN CHILD CARE.

Applicant�s Signature: Date:

 

ANIMAL GUIDELINES AND AFFIDAVIT

REQUIREMENTS FOR CHILD CARE LIABILITY COVERAGE:

Children enrolled in your child care should NOT be in contact with any animals.

I UNDERSTAND AND ACKNOWLEDGE THAT I HAVE NO INSURANCE COVERAGE FOR, NOR DOES MARKEL INSURANCE COMPANY HAVE ANY DUTY TO DEFEND OR INDEMNIFY ANY LOSS ARISING OUT OF ANIMALS OWNED BY THE APPLICANT NAMED ABOVE, ANIMALS OWNED BY ANYONE LIVING WITH OR VISITING WITH THE APPLICANT ABOVE. “ANIMALS” INCLUDES, BUT IS NOT LIMITED TO HORSES, GOATS, DOGS AND CATS. THIS AFFIDAVIT ALSO APPLIES TO ANY RENEWAL POLICIES.

Applicant�s Signature: Date:

 

SWIMMING POOL GUIDELINES AND AFFIDAVIT

REQUIREMENTS FOR CHILD CARE LIABILITY COVERAGE:

  1. Children enrolled in your childcare are NOT allowed to use the pool.
  2. In-ground swimming pool is completely fenced with at least a four-foot fence. Gates are kept locked. If swimming pool is an above ground pool, ladders are completely removed from the pool's side so that no one can enter the pool.
  3. All pool chemicals are kept in a locked storage area.

I UNDERSTAND AND ACKNOWLEDGE THAT I HAVE NO INSURANCE COVERAGE FOR, NOR DOES MARKEL INSURANCE COMPANY HAVE ANY DUTY TO DEFEND OR INDEMNIFY ANY LOSS ARISING OUT OF THE OWNERSHIP, RENTAL, MAINTENANCE, OPERATION, SUPERVISION OR USE BY ANY PERSON OF ANY SWIMMING POOL OR WADING POOL*, OR RELATED SUPPLIES AND EQUIPMENT ON THE INSURED PREMISES. THIS AFFIDAVIT ALSO APPLIES TO ANY RENEWAL POLICIES.

*The Swimming Pool Exclusion on the liability policy does not apply to wading pools 18 inches or less in depth, with size less than 8 feet by 8 feet and constructed of plastic.

Applicant�s Signature: Date:

 

After you click continue you will be directed to select your coverage limits and payment method.