STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
AFFIDAVIT REGARDING LIABILITY INSURANCE
FOR FAMILY CHILD CARE HOME
SECTION A:
I/We, the parent(s)/guardian(s) of_________________________________________________________
(Child's Name)
,
acknowledge that _____________________________________________________________________________________,
(Licensee'sName)
the licensee of _
______________________________________________________________________________________,
(Name of Family Child Care Home)
has informed me/us that this facility does not carry liability insurance or a bond in accordance with standards established by
Family Child Care statute.
SECTION B: To be completed only if licensee does not own premises or the licensee is a member of a condominium
or Homeowner's Association.
I/We, the parent(s)/guardian(s) of
_________________________________________________________,
(Child's Name)
acknowledge that ___
___________________________________________________________________________________,
(Licensee's Name)
the licensee of______
__________________________________________________________________________________.
(Name of Family Child Care Home)
has informed me/us that she/he does not own the premises or is a member of a condominium or Homeowner's Association,
and the liability insurance, if any, of the owner/Homeowners' Association may not provide coverage for losses arising out of, or
in connection with, the operation of the family child care home, except to the extent that the losses are caused by, or result
from, an action or omission by the owner/Homeowners' Association, for which the owner/Homeowners' Association would
otherwise be liable under the law.
Signature of Parent(s)/Guardian(s) Date
NOTE: The law requires Family Child Care providers to carry liability insurance or bond in the amount of $300,000 annually or
to maintain this signed statement in the facility file. Lack of a bond or insurance does not effect the right of parents to bring
legal action against the facility.
LIC 282 (8/08)
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