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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
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Childcare Insurance Application
VA@dmin
2024-11-27T19:26:15+00:00
Childcare Insurance Application Form
Childcare Insurance Application Form
"
*
" indicates required fields
First Name
*
Last Name
*
Contact Email
*
Contact Phone
*
DOB
*
MM slash DD slash YYYY
Social Security #:
*
Or FEIN #
*
Legal Name of Daycare:
*
Year Business was founded?
*
Yrs. in Business
*
Hidden
DOB
Business / Property Address
*
City
State / Province / Region
ZIP / Postal Code
Billing Address
*
Same as Business / Property Address
City
State / Province / Region
ZIP / Postal Code
Name of current or prior Insurance carrier?
*
What is the expiration date?
MM slash DD slash YYYY
Website
Hours of Operation: From
Hours
:
Minutes
AM
PM
AM/PM
- To
Hours
:
Minutes
AM
PM
AM/PM
Projected Gross Revenue in 12 months: $
*
Are there Outside investors or silent investors?
*
Yes
No
Projected Annual Payroll: $
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Do you provide Subcontractors or workers with a 1099 or pay them with cash (excluding owners and officers)?
*
Yes
No
Are there employee benefits?(401K, Health Insurance, etc...)
*
Yes
No
Number of Employees Full time
Part time
Number of Volunteers
How many infants (0-12 months)?
Total Enrolled
Licensed Capacity
Age range of children in care: 12 months and up
Do you take care of children with special medical needs?
*
Yes
No
If so, please describe:
Do you offer overnight services?
*
Yes
No
Are All Employees CPR Certified?
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Yes
No
Is there a background check for all employees?
*
Yes
No
How often?
Do you go on Field Trips?
*
Yes
No
If so, please describe
Do you conduct water activities?
*
Yes
No
If so, please describe
Are pets allowed?
*
Yes
No
If so, please describe
Are there stairs in the building?
*
Yes
No
Additional Insured DES?
*
Yes
No
Notes:
What year was the building built?
Has the building been renovated
*
Yes
No
What is the roof type?
Date of roof replacement or repair?
Date of Plumbing Repairs?
AC Repairs/ replacement dates?
Building Description ie. one story, two story, brick, stucco, roof type, etc. (Please attach photos of building and playground)
File
Max. file size: 128 MB.
How many Square feet of home/building?
Is your building sprinklered?
*
Yes
No
Percentage (%)
Amount of Personal Property coverage needed? $ (Furniture, Toys, computers, equipment, etc)
Copy of claim history attached?
*
Yes
No
Copy of Certificate Attached?
*
Yes
No
Copy of Day Care License attached?
*
Yes
No
File
Max. file size: 128 MB.
Do you need Work Comp?
*
Yes
No
If so, please include your EIN #
Are there Outside investors or silent investors?
*
Yes
No
Is the business Licensed, certified, or registered by a state agency to provide day care services?
*
Yes
No
Has the license ever been revoked or suspended?
*
Yes
No
Does the Business provide transportation for children, including pick up/ Drop off?
*
Yes
No
Do you transport children to/from school?
*
Yes
No
If you need AUTO insurance, please include a list of
ALL DRIVERS
and the following information:
Drivers Full Name
Date of Birth
Drivers License Number
Vin Number for all Vehicles
Upload Document
Max. file size: 128 MB.
*This application is true and complete to the best of my knowledge.
Printed Owner Name:
*
Date
*
MM slash DD slash YYYY
Signature
*
CAPTCHA
To submit your application, please type the word "white"
*
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