CALIFORNIA APPLICATION for FAMILY CHILD CARE LIABILITY INSURANCE

Mail To: Accord Insurance Services, P.O. Box 4485, Thousand Oaks California 91359-1485

Mandatory Information ALL questions must be answered and you must sign and date the application or your application will be returned

Please Note Eligibility: California Family Day Care Providers Only

Print this form, fill it out, send us a copy of your license (or letter from Social Services) and your payment, payable to Accord Insurance Services.

1	Name of Provider
2	Name of Facility if Different from #1
3	Site Address
4	Mail Address (if different)
5	Telephone Number
6	e-mail address
7	Maximum Number of Children Handled at Any One Time
8	Child Care Associations of which You are a member
9	Are You licensed by the State of California as a Family Child Care Facility?
9a	Please provide your facility number and effective date
10	Do you use or have swimming facilities other than a wading pool?	(Note: A wading pool is up to 18" deep)
10a	If YES, are children in your care allowed to use them?	(Note: Pool use is not allowed in this program)
10b	If YES, is the pool fenced on all sides with a self-locking gate?
11	Is there an Additional Insured ($25 each extra)
11a	if YES, explain, list name & address on separate page add $25 each to deposit)
12	Do You own a dog?
12a	If YES, state breed(s)*
12b	If YES, How are dogs kept away from the children?
13	Have you had any claims or injuries in the past five (5) years
13a	Describe All Incidents (use separate sheet, if necessary)
14	Do You have someone to back You up in case of emergency?
15	Do You accept any boarders in your home?	(Note: A boarder rents a room in your home)

Check Here# of Children		Select Liability Limits per occurrence limit/ Aggregate limit/Medical Payment Limit	Full Annual Amount	Minimum Deposit	9 Monthly Payments (Paid over 9 Months)
	1-8	25,000/50,000/5,000	295	118.00	22.44
	1-8	50,000/100,000/5,000	385	154.00	28.55
	1-8	100,000/300,000/5,000	430	172.00	31.89
	1-8	300,000/900,000/5,000	525	210.00	38.94
	1-8	500,000/1,500,000/5,000	590	236.00	43.76
	1-8	1,000,000/3,000,000/5,000	690	276.00	51.18
	9-14	25,000/50,000/5,000	420	168.00	31.15
	9-14	50,000/100,000/5,000	555	222.00	41.16
	9-14	100,000/300,000/5,000	625	250.00	46.35
	9-14	300,000/900,000/5,000	770	308.00	57.11
	9-14	500,000/1,500,000/5,000	869	347.60	64.45
	9-14	1,000,000/3,000,000/5,000	1020	408.00	75.65

Total Cost Including Premium and Fees (Rates are Subject To Change)

PAYMENT METHOD

A	Payment In Full by attached Check (payable to ACCORD INSURANCE SERVICES)
B	Payment of Minimum Deposit by attached Check (payable to ACCORD INSURANCE SERVICES)
		Nine subsequent installments to be paid monthly.
This Form Must Be Completed, Signed and mailed to us.

Accord Insurance Services, 0E77960
Box 4485, Thousand Oaks CA 91359-1485
Talk (800)247-5098
fax (800)501-0905

Premium Finance Contract

Check Here # of Children		Select Liability Limits per occurrence liability limit/ Aggregate liability limit/Medical Payment Limit	Full Annual Amount	Minimum Deposit	Finance Charge	9 Monthly Payments (Paid Over 9 Months)	Total Cost when Financed
	1-8	25,000/50,000/5,000	295	118.00	24.96	22.44	319.60
	1-8	50,000/100,000/5,000	385	154.00	25.95	28.55	410.95
	1-8	100,000/300,000/5,000	430	172.00	29.01	31.89	461.89
	1-8	300,000/900,000/5,000	525	210.00	35.46	38.94	560.46
	1-8	500,000/1,500,000/5,000	590	236.00	39.84	43.76	629.84
	1-8	1,000,000/3,000,000/5,000	690	276.00	46.62	51.18	736.62
	9-14	25,000/50,000/5,000	420	168.00	28.35	31.15	448.35
	9-14	50,000/100,000/5,000	555	222.00	37.44	41.16	592.44
	9-14	100,000/300,000/5,000	625	250.00	42.15	46.35	667.15
	9-14	300,000/900,000/5,000	770	308.00	51.99	57.11	821.99
	9-14	500,000/1,500,000/5,000	869	347.60	58.65	64.45	927.65
	9-14	1,000,000/3,000,000/5,000	1020	408.00	68.85	75.65	1088.85

To Accord Insurance Services

Premium Finance Request Form

C	Name of Applicant
	Applicant's Mailing Address

	Requests you arrange the financing of their premium into six monthly installments.

D	The applicant/insured has made a down payment as checked above. The remaining balance of the premium is to be financed by Thomco Premium Finance. The total of payments will be the amount financed plus the appropriate finance charge.
E	The applicant/insured hereby appoints ACCORD INSURANCE SERVICES attorney in fact and grants full authority to complete and execute a premium finance agreement on their behalf.
IMPORTANT: PRINT THIS FORM BEFORE YOU SUBMIT IT TO US.

I Understand that my coverage can become effective as early as the next working day after Accord Insurance Services receives this completed form, signed & dated, my premium deposit and a copy of my license