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Applicant Statement & Signature: This application, loss information and ACORD applications are understood to be an inducement to the issuance of a policy of insurance by Company. The undersigned hereby A. Authorizes Company to obtain information necessary for evaluation in determining acceptability including, but not limited to, credit reports and physical inspections. B. Warrants that all answers to questions are true and correct to the best of the applicants belief and knowledge
Applicants Signature
(required)
Date
(required)
GENERAL INFORMATION||
Legal name to be shown as First Named Insured on policy:
DBA Name:
Email Address
Website Address
School Type
Charter School
Independent/Private School
Montessori School
Is Your School Accredited?
Yes, By Whom?
No
Date School was Founded
Grades Offered
Current Student Enrollment
Prior Year
Second Prior Year
Describe the Administrators / Principals Background & Qualifications
Do you plan any renovations or new construction in the next 12 months?
Yes
No
If yes, please explain:
Does your school participate in Standardized Testing?
Yes
No
Does your school have a Preschool or Childcare Program that is separately licensed?
Yes
No
If yes, please complete and submit Supplemental Childcare Questionnaire.
Do any of your students attend your school because they have been removed from other schools due to violent and/or Criminal Behavior?
Yes
No
How Many?
Do you have any fund raising activities that require a permit or license from local authorities, invite the general public onto your premises OR include serving or sale of alcohol?
Yes
No
Will your school have a budget deficit this year?
Yes
No
If Yes, what is the amount of the deficit and how do you plan to fund the deficit?
Did your school have a fund deficit last year?
Yes
No
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