Commercial Child Care Applicant Information

SECTION 1

Proposed effective date:

Name insured:*

DBA:

Phone #*

Email:*

Fax #:

Mailing address:

County:*

Zip code:*

City:

State:

Website:

Contact person & phone number:*

1. Type of entity: CorporationIndividualPartnershipJoint ventureLLCOther-enter below

Other

2. Do you offer overnight care? YesNo

3. Do you offer drop-in care? YesNo

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

5. License capacity:

6. 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/$2,000,000Other-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/$1,000,000Other-enter below

Other:

SECTION 3 – CLAIM AND LOSS INFORMATION

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

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

3. List all claims or losses in the past 5 years:

Date of claim or loss:

Type of claim or loss:

Description 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 $:

4. More than 2 claims or losses in the past 5 years?: YesNo

4a. If yes, how many?:

Only complete if interested in obtaining property and/or contents coverage.

SECTION 4 – PROPERTY INFORMATION

Location #:

Location address:

Year built:

1. Contents coverage: YesNo

Amount:

2. Is the building built specifically for child care operations? YesNo

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

Roof:

Plumbing:

Electrical:

HVAC:

4. Do you own the building at this location? YesNo

5. Wind coverage: IncludeExclude

5a. Wind deductible: 2%5%7%10%

6. More than 1 location? YesNo

6a. If yes, how many total?

How did you hear about FDCI? Magazine adReferralConvention/ConferenceInternet SearchOther

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.
Thank you for choosing FDCI.