Core Product -Childcare Supp v.Jan/2011 Page 1 of 2
CHILDCARE, HEADSTART OR LA
TCHKEY FACILITIES
SUPPLEMENTAL APPLICATION
Named Insured
Name of the Facility or organiz
ation_________________________________________________________________
Location Address:________________________________________________________________________________
Hours of Operation:_______________ No. of Staff members:______________ No. of children enrolled____________
1. Are all of your childcare locations licensed by your state’s regulatory agency?
Yes No
If No, provide details.__________________________________________________________________
2. Does the ratio of staff to children meet state requirements?
Yes No
3. Are the director and staff members certified and trained?
Yes No
4. Are criminal background checks conducted on all staff, including employees & volunteers?
Yes No
5. Are children taken off site for any activities?
Yes No
6. What was the date of the last inspection by licensing agency? _______________________
Were any violations or deficiencies noted? Yes No
If yes, attach a copy of the inspection report.
7. Are there written procedures in place including rules, codes of conduct and disciplinary measures
for sexual abuse prevention?
Yes No
8. Is training provided for staff and volunteers on policies and procedures on child abuse prevention?
Yes No
9. If your facility was built prior to 1980, have all premises been inspected and certified
lead free? Yes No
10. Do you have an outdoor play area?
Yes No
If yes,
a) Does the value of your outdoor equipment, including surfacing, exceed $25,000? Yes No
If yes, attach a schedule of locations with equipment values at each.
b) Was all equipment manufactured by a commercial manufacturer? Yes No
c) Was all equipment installed by an insured contractor?
Yes No
11. Does your organization provide accident insurance for children?
Yes No
If yes,
a) Insurance Company:________________ Policy Number:_________________
Policy Period:______________________ Limits:________________________
b) Accident Insurance applies: to all children optional, at child’s expense
12. Is transportation provided for children?
Yes No
13. Does your organization own or lease vehicles?
Yes No
14. Have any allegations or incidents been reported or are know to have occurred?
Yes No
If yes, please provide complete details.____________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
15. Have any staff members been transferred or discharged due to allegations or incidents of child abuse?
Yes No If yes, please provide complete details.________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
