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PO Box 50580 Mesa, Arizona 85208 United States
childcare@wilcockinsurance.com
(480) 464-2288
Outside Arizona
1-800-657-0981
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Commercial Child Care
Licensed In-Home Child Care Provider
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Child Care/ Commercial Auto-Information
VA@dmin
2024-11-27T19:24:25+00:00
Child Care/ Commercial Auto-Information
Child Care/ Commercial Auto-Information
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Contact Name
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Date
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Address
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City
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Zip
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Phone # (Cell/Home)
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E-mail
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DOB
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Business Type:
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Individual
LLC
Corporation
Partnership
Business Name:
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Business Address:
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Street Address
City
State
ZIP
Name of current or prior Insurance carrier?
What is the expiration date?
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Are any vehicles used to transport passengers to/from home?
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Yes
No
Are all listed vehicles owned or leased by the business?
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Yes
No
Are any listed vehicles used to transport passengers from centers to school?
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Yes
No
DRIVER INFORMATION:
Name
DOB
DL#
Tickets / accidents?
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VEHICLE INFORMATION:
Year
Make
Model
VIN #
Full Y/N
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AUTO COVERAGE:
Start Date:
MM slash DD slash YYYY
Bodily Injury / Property Damage
UM/UIM
Comp Deductible
Collision Deductible
Glass:
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Yes
No
Towing:
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Yes
No
Rental:
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Yes
No
Accidents/Tickets
Special Coverage
Notes
Signature
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Date
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Tickets or Accidents in the Last Five years
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Yes
No
Please Provide Details
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