PreSchool, Day Care,
Enrichment Center, Infant Center


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Special Liability Quote Application
 
General Information
1 Proposed Named Insured
(as it appears on your license)
2 Mail
Address
3 City/ST/Zip
4 Site
Address
5 Desired Effective Date
6 Applicant is
7 Contact

8 Telephone#
9 Fax
10 Email
Check the boxes that describe your operations
11
Day Care
Center

 Service
Agency

 Infant
Center

 Residential
Care
Head
Start

 Camps

 Enrichment
Center

 Computer
Lab
Grade
School

 Counseling
Center

 Club

 Teen
Center
12 Years in business
13 Years at this site
14 Building Age
15 Year Refurbished
16 Do you
17 Building square footage is
18 Percentage of Total You Occupy
19 Building type of Construction
20

Building has how many stories
21

Are Premises Multiple Use

if Yes, describe
22 What are your hours of operation
23 How many days per week are you open
24 Do Children stay over night
25

Any weekend or holiday care
26

Do you cook, other than microwave?
27

Pre-packaged foods only?
28

Children allowed in kitchen
29

Deep Fat Frying
30 Is laundry done on the premises
31 What type of fire alarm do you have
32 Regarding Fire Sprinklers
33 What type of burglar alarm do you have
34 Is any ground surface covered with gravel
35 Do you have a trampoline
36 Is There A Pool on the Premises
37 Is Your Facility Licensed By
38 When was your site last inspected
39 What is your licensed capacity
40 What is the age range
41 How many off-site field trips occur per year
42 How to you get there
43 Are any field trips out of State
44 Any animals at school

if Yes, describe

  
45 How many full time employees
46 How many part time employees
47 How many parent/guardian volunteers
48 Do you have a written safety plan
49 Do you have a written employee handbook
50 Do you maintain a record of medical information
51 Do you have a Workers Compensation Insurance Policy in force
52 Have you verified personal references and checked for possible criminal records of your staff
53 Is there a formalized employee screening and monitoring procedure
54 Is Staff trained in First Aid
55 Is Staff trained in CPR
56 How often are personnel records updated
56 Has any person in your organization been implicated, arrested or convicted of any crime that could restrict your license
57 Have you had liability insurance previously
58 Have you had any claims paid, alleged or pending in the last three years

Coverage Needed
Premises Liability
Completed Operations
Products
Personal Injury
Incidental Contractual
Professional
Abuse, Assault & Battery
Certain Criminal Defense
Hired & Non-Owned Auto
Student Accident Limit

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General Agreement

THIS APPLICATION MAY NOT BE USED TO BIND COVERAGE AND NO COVERAGE COMMENCES. Completion of this application is for the purpose of transmitting information only. Any agreement or contract binding insurance coverage must be done on a separate document. COVERAGE WILL COMMENCE only upon the effective date of a separate binding insurance document (e.g., binder, certificate of insurance, or policy).
I/WE HEREBY DECLARE that the foregoing statements and answers herein are true and complete and that no circumstance or information concerning the subject matter of the questions asked has been omitted or withheld. I/WE understand that the statements and answers herein will be relied upon by ACCORD INSURANCE SERVICES. I/WE understand that any misrepresentation or inaccuracies regarding statements and answers given herein may constitute a basis for rescinding such binding insurance document as may be issued.
I AGREE
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