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Please fill out the entire form. This form has five pages and takes approximately 15-20 minutes to fill out.
CCIPRO’S CHILD CARE APPLICATION
Todays Date:
(Required)
BASIC INFORMATION
Proposed Effective Date:
Proposed Expiration Date:
All Named Insureds
Is there more than 50% common ownership between all named insureds?
Yes
No
Mailing address:
Loc 1 Address:
Loc 2 Address:
Loc 3 Address:
Website Address:
Email Address:
Loss Control Contact Name:
Loss Control Contact Phone #:
Type of legal entity
Individual
Partnership
Corporation
Joint Venture
LLC
Not for Profit Organization
Type of childcare Operations:
Center
Headstart
Montessori
Sick Child
Before/After School
Special Needs
Nursery/PreK
Parent Coop
Greater than 50% Drop-in
Do you have operations other than childcare?
Yes
No
If yes explain:
Date business started under current ownership:
Is this a renewal?
Yes
No
Current Carrier:
Is this policy being non-renewed?
Yes
No
Expiring Premium:
GL:
Prop:
Auto:
List all losses in the last five years:
Date of Claim
Description of Claim
Open/Closed
Paid $
Reserve $
Have you had any bankruptcies, tax or credit liens against you in the last 5 Years?
Yes
No
If yes explain:
GENERAL INFORMATION
Are you accredited by:
NAEYC:
Yes
No
NECPA:
Yes
No
What is your licensed capacity?
Loc 1:
Loc 2:
Loc 3:
What is your average daily number of infants (18 months and younger)?
Loc 1:
Loc 2:
Loc 3:
Has your childcare license ever been suspended or revoked at any of your locations?
Yes
No
If yes explain:
Are you open more than 12 hours a day and 5 days a week at any of your locations?
Yes
No
If yes explain:
What is your average standard weekly tuition rate per child?
Child Care Insurance Professionals
1484 South Main Street
Salt Lake City, UT 84115
Tel:
888.812.9992
Fax:
888.817.3332
Email:
info@ccipros.com