Commercial Child Care Application

Step 1 of 4

25%

Name Insured(Required)

DBA

Phone(Required)

Email(Required)

Fax Number

Mailing Address

Street Address City State ZIP Code

Website

Contact person & phone number(Required)

Type of entity

Corporation

Individual

Partnership

Joint Venture

LLC

Other - specify below

Other

Do you offer overnight care?

Do you offer drop-in care?

Number of additional named insureds (for example: ELC’s and /or Landlords)

License capacity

Average daily attendance (based on 12 months)

Section 2 - Liability Limits & Coverage (per occurrence limit/aggregate limit)

General liability limits

$100,000/$300,000

$300,000/$600,000

$1,000,000/$1,000,000

$1,000,000/$2,000,000

Other-enter below

Other

Abuse liability (INCLUDED) $25,000/$50,000

Abuse liability limits (optional)

$100,000/$300,000

$500,000/$1,000,000

$1,000,000/$1,000,000

Other-enter below

Other

Section 3 - Claim and Loss Information

Have you had any claims or losses in the past 5 years?

Have you ever had any incidents or allegations of sexual or physical abuse?

List all claims or losses in the past 5 years

Date of claim or loss

Type of claim or loss

Status (open/closed/not filed)

Paid $

Reserve $

Date of claim or loss

Type of claim or loss

Description of claim or loss

Status (open/closed/not filed)

Paid $

Reserve $

More than 2 claims or losses in the past 5 years?

If yes, how many?

Section 4 - Property Information

Location #

Location address

Year built

Contents coverage

Amount

Is the building built specifically for child care operations?

Please list updates (month/year) to the building for each of the following:

Roof

Plumbing

Electrical

HVAC

Do you own the building at this location?

Wind coverage

Wind deductible

More than one location?

If yes, how many in total?

How did you hear about FDCI?

Magazine Ad

Referral

Convention/Conference

Internet Search

Other

Describe

NOTE: Coverage cannot be bound until the Company approves your completed application. The Company’s receipt of premium does not bind coverage until a fully completed and signed application is received. Before electronically signing this document, verify your information is correct. Electronically signing will disable further editing of your application.

Commercial Child Care Policy Application

Section 2 - Liability Limits & Coverage (per occurrence limit/aggregate limit)

Section 3 - Claim and Loss Information

Section 4 - Property Information

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