Fill - Free fillable CHILD CARE CENTER RENEWAL SUPPLEMENT (Philadelphia Insurance Companies) PDF form

CHILD CARE CENTER RENEWAL SUPPLEMENT

Web address:

Named Insured:

Location address:

E-mail:

Phone number:

Is the child care center licensed?

If licensing is NOT state required, why is the center exempt:

Has a license to operate ever been denied, suspended or revoked? Yes No

Yes No

Yes No Is the Applicant’s organization more than 25% owned by a private equity fund structure?

If yes, provide name of private equity firm:

or Business Income ALS – complete worksheet

STAFF AND CHILDREN

CHILD AGE GROUP # OF CHILDREN AVERAGE DAILY ATTENDANCE # OF TEACHERS

Infants, ages 0 -1

Toddlers, ages 1 -2

Toddlers, ages 2 - 3

Preschoolers, ages 3 - 5

School Age Children

a. Yes No

Is any staff less than 18 years old?

If yes, indicate specific duties for each:

b. Yes No Does the Applicant use any volunteers?

If yes, indicate specific duties for each:

c. Is a minimum of one staff member certified in first aid present at all times?

Yes No

d. OPTIONAL: If male staff, provide details of:

i) length of employment:

ii) any one on one? Yes No

iii) duties performed, including age groups:

2. Describe any new programs added over the last year, i.e. field trips to zoo, etc.

3. Provide expiration month and year of current license:

4. Provide current policy dates of the Applicant’s current Accident & Health policy:

5. Yes No Are there operable surveillance cameras in all classrooms and inside play areas?

If yes, is the video saved? Yes No If yes, for how long:

6. Yes No Does the Applicant contract with any vendors who have contact with any children in your care?

If yes, please explain:

Yes No

Are there any other circumstances where adults, who are not the Applicant’s employees, have

access to any child in your care?

If yes, explain

Child Care Center Renewal

Page 1 of 7

09/2018

Print Application

Clear Application

SECURITY

1. Are any of the Applicant’s locations protected by security personnel? Yes No

2. If yes, are the security personnel

a. Sub-contracted? Yes No

b. Employed? Yes No

c. Other: (please explain)

3. Does the Applicant’s state permit open and / or concealed carry of weapons on your premises? Yes No

4. Does the Applicant have a written policy permitting open and/or concealed carry of firearms on

any premises for which you are requesting insurance coverage?

Yes No

If the Applicant permits open and / or concealed carry of firearms on any premises for which

you are requesting insurance coverage, please identify who you grant this permission to:

a. Staff? Yes No

b. Guests? Yes No

6. If the Applicant does not permit open and/or concealed carry of firearms on any premises for

which you are requesting insurance coverage, do all locations have signage which

conspicuously identifies the building as a Gun Free Zone?

Yes No

BUSINESS INCOME ACTUAL LOSS SUSTAINED

A. Business Incomes exposures from the following sources

ACTUAL REVENUE FOR PAST 12 MONTHS

1. Total Annual Tuitions $

2. Ordinary Payroll Expense* $

3. Continuing Expenses $

$ B. Total B/I Exposure for 12 months

C. Less Cost of:

1. If excluding or limiting “Ordinary Payroll”, deduct all “Ordinary

Payroll” Expenses. (See note below.) If not excluding or

limiting “Ordinary Payroll”, leave blank. $

2. Other Non-continuing Expenses(describe) $

$ D. Total Deductions (Items 1 – 2)

E. Total Business Income Value: (B – D) $

Complete only if extra expense is requested**

$ F. Method 1: 25% of Total Revenue

G. Method 2: Calculation by Category**

1. Rental for temporary Child Care location $

2. Moving Expenses $

3. Overtime / Other extra expense $

4. Other(describe): $

H. Total Gross Extra Expense $

Deduct expenses discontinued at original location because of loss ($ )

I. Net Extra Expense: (From line F or Line H) $

J. TOTAL INSURABLE BUSINESS INCOME / EXTRA EXPENSE

(E + I) (Agreed Amount) $

Ordinary Payroll expenses include payroll, employee benefits if directly related to payroll, FICA and Medicare payments,

union dues, and Workers Compensation premiums. Some points to consider in deciding whether to exclude or limit

Ordinary Payroll (ie: other than officers, executives, managers and employees under contract).

Each Employee: $

UMBRELLA : If Umbrella covers Employer’s Liability

Each Accident: $ Policy Limit: $

Carrier:

Term: to

Child Care Center Renewal

Page 2 of 7

09/2018

Clear Application

Print Application

Could you get them back when operations are restored or would they have gone

elsewhere?

Yes

Describe:

Extra Expense Coverage provides additional coverage in the event of a covered loss for necessary expenses

sustained during the period of restoration that you would not have incurred if there had been no direct physical

loss or damage to property. For example, if it becomes necessary for you to rent another building at another

unnamed location in order to continue your operations during the period of recovery. Two methodologies are

being offered to determine your Extra Expense exposure. Which methodology you use is up to you.

Would you lay off all your other employees in the event of a short interruption?

Yes No

Describe:

Would yo

u lay o

ff all your other employees in the event of a short interruption?

Yes No

Describe:

AUTOMOBILE

1. Yes No Does the Applicant’s organization utilize GPS fleet telematics devices?

If yes, please check off the fleet telematics being utilized:

Plug in Hard wired Mobile Phone Other:

2. What percentage of the Applicant’s fleet is provided with these fleet telematics devices? %

3. Yes No Does the Applicant have a formal driving policy in place with MVR standards?

If yes:

a. Is driving policy communicated in writing to all employees? Yes No

b. Yes No Is a signed acknowledgement form kept on file?

If yes, please provide a copy of signed acknowledgement.

c. Do driving standards include the following:

Yes No

No major violations including DUI, racing, hit and run, speeding in excess of 20 mph

over posted speed limit, manslaughter?

No more than 2 moving violations within past 3 years?

No more than 1 at fault accident within past 3 years? Yes No

4. How often does the applicant check MVR reports?

5. Does the Applicant allow any newly hired drivers to operate vehicles without going through a

company-specific documented driver training? Yes No

6. Describe any ongoing training provided to drivers:

7. Yes No Does the Applicant allow employees to drive personal vehicles for company purposes?

If yes:

a. Are the driving policy and standards for these drivers the same as in questions 3-5? Yes No

b. Does the Applicant require these employees to have adequate personal insurance limits? Yes No

Child Care Center Renewal

Page 3 of 7

09/2018

Clear Application

Print Application

WINTER WEATHER FREEZE-UP PROTECTION

1. Fire Protection and Testing

a. Is the building provided with an Automatic Fire Sprinkler System (AS)? Yes No N/A

i. If yes, approximately what percentage (%) of the building is sprinklered? %

ii. If yes, what type of sprinkler system is installed? Wet-Pipe Dry-Pipe Both

iii. If yes, when possible, is the sprinkler piping primarily run within conditioned

areas designed to ensure the temperature remains above the 45°F minimum

Yes No N/A

iv. If yes, is the testing & inspection by qualified sprinkler contractor completed

within past 12 months & includes a formal winterization review?

Yes

N/A

v. If yes, are the alarms tied to a 24 hour UL listed monitoring company?

Yes

N/A

2. Emergency Water Response (domestic and AS water lines)

a. Are water shutoff valves (domestic and AS water lines) marked and readily

accessible?

Yes

N/A

b. Are water shutoff valves exercised (closed and reopened) at least annually?

Yes

N/A

c. Is the staff qualified to respond and shut off the water main during normal business

hours and off hours?

Yes

N/A

3. Automatic Water Shutoff Devices

a. For domestic water lines, is there a water flow detection, notification and automatic

shutoff?

Yes

N/A

4. Unused/Vacant Spaces

a. Does Applicant have a formal process to turn off and drain domestic water lines for

these spaces?

Yes

N/A

5. Unheated Areas (attics, crawl spaces, exterior wall joists)

a. Are all domestic water lines located in areas heated to at least 45°F?

Yes

N/A

i. If no, please describe freeze prevention measures (e.g. temperature monitoring,

heat trace, full insulation):

This section must be completed by all risks that have a location in one of the following states: AR, CT, DC, DE,

GA, IL, IN, KY, ME, MD, MA, MI, MO, NH, NY, NJ, NC, OH, PA, RI, SC, TN, TX, VT, VA, WV, WI

temperature?

1. If no, please describe freeze prevention measures (

e.g. temperature

monitoring, heat trace, full insulation on piping or

roof):

General Comments:

Child Care Center Renewal

Page 4 of 7

09/2018

Print Application

Clear Application

FRAUD STATEMENT AND SIGNATURE SECTIONS

The Undersigned states that he/she is an authorized representative of the Applicant and declares to the best of his/her knowledge and belief

and after reasonable inquiry, that the statements set forth in this Application (and any attachments submitted with this Application) are true

and complete and may be relied upon by Company * in quoting and issuing the policy. If any of the information in this Application changes

prior to the effective date of the policy, the Applicant will notify the Company of such changes and the Company may modify or withdraw the

quote or binder.

The signing of this Application does not bind the Company to offer, or the Applicant to purchase the policy.

*Company refers collectively to Philadelphia Indemnity Insurance Company and Tokio Marine Specialty Insurance Company

VIRGINIA APPLICANT: READ YOUR POLICY. THE POLICY OF INSURANCE FOR WHICH THIS APPLICATION IS BEING MADE, IF ISSUED,

MAY BE CANCELLED WITHOUT CAUSE AT THE OPTION OF THE INSURER AT ANY TIME IN THE FIRST 60 DAYS DURING WHICH IT IS IN

EFFECT AND AT ANY TIME THEREAFTER FOR REASONS STATED IN THE POLICY.

FRAUD NOTICE STATEMENTS

ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR

INSURANCE CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS, FOR THE PURPOSE OF MISLEADING, INFORMATION

CONCERNING ANY FACT MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND SUBJECTS THAT PERSON TO

CRIMINAL AND CIVIL PENALTIES (IN OREGON, THE AFOREMENTIONED ACTIONS MAY CONSTITUTE A FRAUDULENT INSURANCE ACT WHICH MAY

BE A CRIME AND MAY SUBJECT THE PERSON TO PENALTIES). (IN NEW YORK, THE CIVIL PENALTY IS NOT TO EXCEED FIVE THOUSAND DOLLARS

($5,000) AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION). (NOT APPLICABLE IN AL, AR, AZ, CO, DC, FL, KS, LA, ME, MD, MN,

NM, OK, PA, RI, TN, VA, VT, WA AND WV).

APPLICABLE IN AL, AR, AZ, DC, LA, MD, NM, RI AND WV: ANY PERSON WHO KNOWINGLY (OR WILLFULLY IN MD) PRESENTS A FALSE OR

FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR WHO KNOWINGLY (OR WILLFULLY IN MD) PRESENTS FALSE INFORMATION IN AN

APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES OR CONFINEMENT IN PRISON.

APPLICABLE IN COLORADO: IT IS UNLAWFUL TO KNOWINGLY PROVIDE FALSE, INCOMPLETE, OR MISLEADING FACTS OR INFORMATION TO AN

INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE COMPANY. PENALTIES MAY INCLUDE

IMPRISONMENT, FINES, DENIAL OF INSURANCE AND CIVIL DAMAGES. ANY INSURANCE COMPANY OR AGENT OF AN INSURANCE COMPANY WHO

KNOWINGLY PROVIDES FALSE, INCOMPLETE, OR MISLEADING FACTS OR INFORMATION TO A POLICYHOLDER OR CLAIMANT FOR THE PURPOSE

OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE POLICYHOLDER OR CLAIMANT WITH REGARD TO A SETTLEMENT OR AWARD PAYABLE FROM

INSURANCE PROCEEDS SHALL BE REPORTED TO THE COLORADO DIVISION OF INSURANCE WITHIN THE DEPARTMENT OF REGULATORY

AGENCIES.

APPLICABLE IN FLORIDA AND OKLAHOMA: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY INSURER

FILES A STATEMENT OF CLAIM OR AN APPLICATION CONTAINING ANY FALSE, INCOMPLETE, OR MISLEADING INFORMATION IS GUILTY OF A

FELONY (IN FL, A PERSON IS GUILTY OF A FELONY OF THE THIRD DEGREE).

APPLICABLE IN KANSAS: AN ACT COMMITTED BY ANY PERSON WHO, KNOWINGLY AND WITH INTENT TO DEFRAUD, PRESENTS, CAUSES TO BE

PRESENTED OR PREPARES WITH KNOWLEDGE OR BELIEF THAT IT WILL BE PRESENTED TO OR BY AN INSURER, PURPORTED INSURER, BROKER

OR ANY AGENT THEREOF, ANY WRITTEN, ELECTRONIC, ELECTRONIC IMPULSE, FACSIMILE, MAGNETIC, ORAL, OR TELEPHONIC COMMUNICATION

OR STATEMENT AS PART OF, OR IN SUPPORT OF, AN APPLICATION FOR THE ISSUANCE OF, OR THE RATING OF AN INSURANCE POLICY FOR

PERSONAL OR COMMERCIAL INSURANCE, OR A CLAIM FOR PAYMENT OR OTHER BENEFIT PURSUANT TO AN INSURANCE POLICY FOR

COMMERCIAL OR PERSONAL INSURANCE WHICH SUCH PERSON KNOWS TO CONTAIN MATERIALLY FALSE INFORMATION CONCERNING ANY FACT

MATERIAL THERETO; OR CONCEALS, FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO.

APPLICABLE IN KENTUCKY: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSONS

FILES AN APPLICATION FOR INSURANCE CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS, FOR THE PURPOSE OF

MISLEADING, INFORMATION CONCERNING ANY MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME.

APPLICABLE IN MAINE, TENNESSEE, VIRGINIA AND WASHINGTON: IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE OR MISLEADING

INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE COMPANY. PENALTIES MAY INCLUDE IMPRISONMENT,

FINES OR A DENIAL OF INSURANCE BENEFITS.

APPLICABLE IN PENNSYLVANIA: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON

FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS FOR THE

PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A

CRIME AND SUBJECTS SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES.

APPLICABLE IN NEW YORK: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON

FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE

PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A

CRIME AND SHALL BE SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE STATE VALUE OF THE CLAIM FOR EACH

SUCH VIOLATION.

NAME (PLEASE PRINT/TYPE) TITLE

(MUST BE SIGNED BY THE PRESIDENT, CHAIRMAN, CEO OR EXECUTIVE

DIRECTOR)

___________________

__________________________________________

SIGNATURE DATE

SECTION TO BE

COMPLETED BY THE PRODUCER/BROKER/AGENT

PRODUCER AGENCY

(If this is a Florida Risk, Producer means Florida Licensed Agent)

PRODUCER LICENSE NUMBER

(If this a Florida Risk, Producer means Florida Licensed Agent)

ADDRESS (STREET, CITY, STATE, ZIP)

Child Care Center Renewal

Page 5 of 7

09/2018

Clear Application

Print Application

CYBER SECURITY LIABILITY ENDORSEMENT – SUPPLEMENTAL

QUESTIONNAIRE

Name of Applicant:

Address of Applicant:

City: State: Zip:

Website: www:

Nature of Operations:

1. Annual sales or revenue: $

2. Does the Applicant collect, store or otherwise handle any Personally Identifiable Information (PII)

belonging to customers, clients, or other third parties, other than employees?

If yes, please indicate the types of Personally Identifiable Information held (check all that apply):

Yes No

a. Social Security Numbers, Bank or Other Financial Account Details, Driver’s License or

other State Identification Numbers

b. Non-public Medical or Healthcare Data, including Protected Health Information (PHI)

c. Credit or Debit Card Information

3. a. During the last three (3) years, has anyone alleged that the Applicant was responsible for

damage to their computer system(s) arising out of the operation of the Applicant’s computer

system(s)?

Yes No

b. During the last three (3) years, has anyone made a demand, claim, complaint, or filed a

lawsuit against

the Applicant alle

ging invasion or interference of rights of privacy or the

inappropriate disclosure of Personally Identifiable Information (PII)?

Yes No

c. During the last three (3) years, has the Applicant been the subject of an investigation or

action by any regulatory or administrative agency for privacy-related violations?

Yes No

d. Is the Applicant aware of any circumstance that could reasonably be anticipated to result in a

claim being made against them for the coverage being applied for?

Yes No

PI-CYBE-APP (11/16)

Page 1 of 2

Clear Application

Print Application

FRAUD STATEMENT AND SIGNATURE SECTIONS

The Undersigned states that he/she is an authorized representative of the Applicant and declares to the best of his/her knowledge

and belief and after reasonable inquiry, that the statements set forth in this Application (and any attachments submitted with this

Application) are true and complete and may be relied upon by Company * in quoting and issuing the policy. If any of the information

in this Application changes prior to the effective date of the policy, the Applicant will notify the Company of such changes and the

Company may modify or withdraw the quote or binder.

The signing of this Application does not bind the Company to offer, or the Applicant to purchase the policy.

*Company refers collectively to Philadelphia Indemnity Insurance Company and Tokio Marine Specialty Insurance Company

FRAUD NOTICE STATEMENTS

ANY PERSON WH

O KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR

INSURANCE CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS, FOR THE PURPOSE OF MISLEADING, INFORMATION

CONCERNING ANY FACT MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND SUBJECTS THAT PERSON TO

CRIMINAL AND CIVIL PENALTIES (IN OREGON, THE AFOREMENTIONED ACTIONS MAY CONSTITUTE A FRAUDULENT INSURANCE ACT WHICH MAY

BE A CRIME AND MAY SUBJECT THE PERSON TO PENALTIES). (IN NEW YORK, THE CIVIL PENALTY IS NOT TO EXCEED FIVE THOUSAND DOLLARS

($5,000) AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION). (NOT APPLICABLE IN AL, AR, AZ, CO, DC, FL, KS, LA, ME, MD, MN,

NM, OK, RI, TN, VA, VT, WA AND WV).