APPLICATION FOR: Day Care/Preschool Accident Insurance
Policyholder Information
Policyholder Name: ____________________________________________________________________________________________________
Mailing Address: ______________________________________________________________________________________________________
Contact Name: ________________________________________________ Phone Number: ________________________________________
Contact Email Address: _________________________________________ Insured Email Address: __________________________________
Plan and Benefits
Effective Date: ____________________________ Expiration Date: _____________________________
Maximum Medical Expense Benefit: $ ____________________________
Accidental Death & Dismemberment Principal Sum: $ ____________________________
Deductible (per claim) $ ____________________________
Type of Coverage: Excess Primary
Coverage for: All Enrollees and Staff of the Policyholder All Enrollees of the Policyholder
Number of Enrollees to be Insured: _______________ Number of Staff to be Insured: _______________
Prior Coverage
Have you had prior coverage? Yes No
What was your current annual policy year enrollment: _____________ Premium: $ _______________
Has coverage ever been declined or cancelled due to losses? Yes No
Declaration and Signature
Applicant declares information provided is true and that no material facts have been suppressed or misstated.
Applicant understands false statements or misrepresentations may result in termination of this insurance contract.
________________________________________________________________________ ____________________________________
Author
ized Signature Date
________________________________________________________________________ ____________________________________
Pri
nted Name Title
Email completed application to: jlynch@aliverisk.com
Agent Data
Agent Name: ______________________________________________ Agency: _______________________________________________________
Address: __________________________________________________ City/State/Zip: __________________________________________________
Phone: ____________________________________ License Number: ______________________ Email: ___________________________________
Signature: _________________________________________________________________ Date: __________________________________________
Day Care/Preschool Acciden
t Insurance Application 011521 Page 1 of 1
aliverisk.com
Alive Risk is a unit of the RSG Underwriting Managers division of RSG Specialty, LLC, a Delaware limited liability company based in Illinois. RSG Specialty, LLC, is a subsidiary of Ryan Specialty Group,
LLC (RSG). Alive Risk works directly with brokers, agents and insurance carriers, and as such does not solicit insurance from the public. Some products may only be available in certain states, and some
products may only be available from surplus lines insurers. In California: RSG Specialty Insurance Services, LLC (License # 0G97516). ©2021 Ryan Specialty Group, LLC
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