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Capitol Specialty Insurance Corporation (Special Risks)

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CQU 002 (11-18) © 2019 CapSpecialty, Inc. All rights reserved. Page 1 of 5
Child Care Center Questionnaire
SUBMISSION REQUIREMENTS:
• Completed ACORD Application
• Currently valued loss runs from current/prior insurance carrier.
I. APPLICANT INFORMATION
1.1
Applicant Name:
DBA Name(s):
1.2
Years under Current Management:
1.3
Applicant child care center is located in which type of facility?
Commercial Building School Church Private Home Municipal Building
Manufactured Classroom Mobile Home Other (describe):
1.4
If Private Home, does Applicant have Homeowner’s Property and Liability Insurance?
Yes No
1.5
Type of Child Care Facility (Check all that are applicable)
Family Child Care Group Child Care
Preschool 4K Head Start School Age (5 and up)
1.6
Hours of Operation: AM to PM
1.7
Is the Applicant a currently licensed childcare facility?
Yes No
If YES, provide the following: License Number:
Original Date of Issuance:
State or Local Authority that Issued:
If NO, please indicate if the following applies to Applicant:
Certified By State or Local Authority Registered With State or Local Authority Unregulated
1.8
If the Applicant’s license has been in effect for less than three years, please describe the Applicant’s child care experience to date,
including the number of years in operation:
1.9
What is Applicant’s licensed capacity (number of children)?
1.10
Does the Applicant comply with its licensed child care ratio and total capacity?
Yes No
1.11
Does the Applicant comply with all state and local licensing requirements for childcare facilities?
Yes No
1.12
Has the Applicant’s license to operate as a childcare facility ever been denied, suspended or revoked, or is any action
pending that could lead to suspension or revocation?
Yes No
1.13
Has the Applicant or any individual owner, employee or volunteer, ever been the subject of any disciplinary or
enforcement action, or any complaint or investigation, by any regulatory authority?
Yes No
If yes to 1.12 or 1.13, please explain thoroughly in a separate attachment, including any corrective action taken.
1.14
Please list all applicable accreditations for Applicant and Applicant’s owner or senior staff members:
II. STAFF AND CHILDREN
2.1
What is the Applicant’s average daily attendance (number of children)?
2.2
Does the applicant use volunteers, now or in the past?
If Yes, describe their roles and responsibilities:
Minimum Age of Volunteers:
2.3
Does the Applicant conduct screening procedures, including comprehensive criminal background checks, on all:
(a) Employees, prior to hire?
(b) Volunteers, prior to volunteering?
2.4
Does the Applicant review the results of such checks and procedures, and consider any negative findings in its
decision to hire an employee or accept a volunteer?
III. CORPORAL PUNISHMENT
3.1
What is the Applicant’s policy on corporal punishment? Allowed Prohibited
3.2
Have there ever been any claims, lawsuits, investigations, incidents or complaints against Applicant or any past or
present staff member involving corporal punishment?
If yes, please provide details in a separate attachment, including any corrective actions taken.
Capitol Specialty Insurance Corporation
A Stock Company
P. O. Box 5900
Madison, WI 53705-0900
Child Care Center Questionnaire
CQU 002 (11-18) © 2019 CapSpecialty, Inc. All rights reserved. Page 2 of 5
IV. HEALTH AND SAFETY
4.1
Does the Applicant provide drop in services? (Drop-in care is when children are accepted for care that are not
currently enrolled or registered with your child care facility.)
4.2
Indicate if a file containing the following information or documentation is maintained by Applicant for each child in its care:
a. Immunization records, which are updated annually?
b. Records indicating any unusual conditions a child has?
c. Signed releases (signed by parents or legal guardians) for emergency medical treatment and dispensing of
medications?
d. Written instructions for dispensing of child’s medication, from the child’s physician?
4.3
Does Applicant require medication to be provided in original packaging, either pharmacy bottle with directions, or
over-the-counter?
4.4
Does the Applicant have an accident medical insurance policy?
If yes:
a. Does coverage apply to all children enrolled in Applicant’s center?
b. Does coverage apply to all staff members?
4.5
Are there any pets or animals kept on premises?
If yes, describe animals (type, breed, number), caging or other method used to secure, and type of interaction with children:
4.6
Does the Applicant allow firearms on premises?
If yes, are firearms kept locked in a safe (no glass), in a room not accessible to children?
4.7
Does Applicant use bottle warmers, crockpots or similar devices to heat bottles?
If yes, how are the devices and their power cords protected to prevent accidental spills and children from accessing?
4.8
Does Applicant use stackable cribs?
4.9
Are infants always placed in cribs for sleeping or rest-time?
4.10
Are “pack-n-plays” or similar portable cribs used by Applicant?
If yes:
a. Are all such units checked for replacement or recall at least once a year?
b. Is firm, snug-fitting mattress and mattress covering used?
4.11
Do Applicant now, or will Applicant, provide either overnight or extended childcare past 8:00 pm, if given the
opportunity?
If yes:
a. Are at least two staff members on duty at such times?
b. Is a staff member required to be awake at all times?
c. Are the doors locked after normal business hours?
d. Are children ever left unattended?
4.12
Does Applicant ever provide transportation for children in your care?
If yes, does Applicant have an auto policy which complies with state law requirements in place for all vehicles in
which Applicant transports children?
V. PLAY AREAS
5.1
Does Applicant have a playground or play area on premises?
Yes No
If yes, please answer the following:
5.2
Is the playground/play area supervised during all times in use?
Yes No
5.3
What equipment do you have on playground/in play area? (Check all that apply.)
Swings Jungle Gym Slide Sandbox
Other (describe):
5.4
Is the playground/play area fenced in?
Yes No
5.5
Is the surface under and around play equipment “kid friendly” (i.e. impact absorbing)?
Yes No
5.6
Is all equipment securely anchored?
Yes No
5.7
What is the maximum height of any of the playground/play area equipment? feet inches
5.8
Is the playground/play area equipment checked regularly for safety?
Yes No
5.9
Does Applicant have any trampolines or bounce houses on premises?
Yes No
5.10
Does Applicant have any elevated indoor play structures?
Yes No
If yes: How far off the ground? feet inches
Describe the floor covering below the structure:
5.11
Does the Applicant ever take children on any off-site field trips?
Yes No
If yes, provide detail:
Child Care Center Questionnaire
CQU 002 (11-18) © 2019 CapSpecialty, Inc. All rights reserved. Page 3 of 5
VI. SWIMMING FACILIITES/POOLS
6.1
Does the Applicant currently allow its enrolled children to use, or in the future does Applicant plan to allow its
enrolled children to use, any type of swimming facilities?
If yes, what type of swimming facilities are used?
(Check all that apply.)
Privately Owned Pool Commercially-Owned Pool Municipal Pool
Public Beach Indoor or Outdoor Water Park Other, please describe:
If you indicated that a POOL is used above, please answer the following:
6.2
Where is the pool located?
On Applicant’s business premises
Away from Applicant’s business premises
6.3
Indicate the following for the pool used:
Swimming Section Wading Section In-Ground Above-Ground
Depth at deepest point: Dimensions: Length - Width -
6.4
Are all swimming pools which Applicant allows its children to use compliant with Virginia Graeme Baker Pool and Spa
Safety Act?
6.5
Are certified lifeguards on duty at all times when the pool is open?
6.6
Is the pool completely fenced with a self-closing and self-locking gate?
If yes, what height is the fence? feet inches
Are all gates locked and secured when pool is not in use?
6.7
Does the pool have a diving board or water slide?
6.8
Is the walking surface around the pool non-skid and in good condition?
6.9
What is the ratio of staff to child at pool? staff to children
6.10
What is the minimum age of children in your care to be allowed in the water?
6.11
Are all pool chemicals locked in a secure area or building that is inaccessible to children?
VII. ADDITIONAL COVERAGES REQUESTED
Select any additional coverages you are requesting and the limits desired:
☐ Abuse or Molestation Coverage
☐ $25,000/$50,000 – no charge
☐ $50,000/$100,000
☐ $100,000/$200,000
☐ $300,000/$600,000
☐ $500,000/$500,000
☐ $1,000,000/$1,000,000
☐ Dog Sublimit: $50,000
☐ Water Activities / Pool Sublimit: $ 100,000
Child Care Center Questionnaire
CQU 002 (11-18) © 2019 CapSpecialty, Inc. All rights reserved. Page 4 of 5
VIII. FRAUD WARNINGS
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.
(Not applicable in AL, AR, CO, DC, FL, KY, KS, LA, ME, MD, NJ, NM, NY, OH, OK, OR, PA, RI, TN, VA, VT, WA and WV).
APPLICABLE IN AL, AR, DC, LA, MD, NM, RI AND WV
Any person who knowingly (or willfully)* presents a false or fraudulent claim for payment of a loss or benefit or knowingly (or
willfully)* presents false information in an application for insurance is guilty of a crime and may be subject to fines and
confinement in prison. *Applies in MD only.
APPLICABLE IN CO
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 FL AND OK
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 (of the third degree)*. *Applies in FL only.
APPLICABLE IN KS
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 commits a fraudulent insurance act.
APPLICABLE IN KY, NY, OH AND PA
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 (not to exceed five thousand dollars and the stated value of the claim for each such violation)*. *Applies in NY
only.
APPLICABLE IN ME, TN, VA AND WA
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 and denial of insurance benefits. *Applies in ME only.
APPLICABLE IN NJ
Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and
civil penalties.
APPLICABLE IN OR
Any person who knowingly and with intent to defraud or solicit another to defraud the insurer by submitting an application
containing a false statement as to any material fact may be violating state law.
APPLICABLE IN VT
Any person who knowingly presents a false statement in an application for insurance may be guilty of a criminal offense and
subject to penalties under state law.
Child Care Center Questionnaire
CQU 002 (11-18) © 2019 CapSpecialty, Inc. All rights reserved. Page 5 of 5
IX. REPRESENTATIONS
This Application must be signed by an authorized partner, officer or other principal of Applicant shown in Question 1.1 of this Application.
By signing this Application, the undersigned represents, on behalf of the Applicant and all proposed insureds, the following:
a.
After conducting due diligence, the statements in the furnished to the Company are accurate and complete;
b.
Those statements furnished to the Company are representations Applicant makes on behalf of all proposed Insureds;
c.
Those representations are a material inducement to the Company to provide a premium proposal;
d.
If a policy is issued, the Company will have issued this Policy in reliance upon those representations;
e.
If there is any material change in the Applicant’s condition or in the Applicant’s activities, services, or answers provided in this Application
that occurs or is discovered between the date this Application is signed and the Effective Date of any policy, if issued, Applicant will
immediately report such material change to the Company in writing; and
f.
The Company reserves the right, upon receipt of such notice, to change or rescind any proposal previously offered by the Company.
As used above, the term “Company” refers to Capitol Specialty Insurance Corporation.
NOTHING IN THIS APPLICATION SHOULD BE INTERPRETED TO MEAN THAT COVERAGE WILL BE OFFERED OR THAT ANY ITEMS REFERENCED IN
QUESTIONS OR ANSWERS TO QUESTIONS WILL BE COVERED EVEN IF COVERAGE IS OFFERED AND BOUND.
SOME RESPONSES MAY REQUIRE MORE SPACE THAN THAT PROVIDED IN THE APPLICATION ITSELF. PLEASE PROVIDE THOSE RESPONSES ON A
SEPARATE PAGE AND ATTACH IT TO THIS APPLICATION.
Signature of authorized representative of Applicant
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Capitol Specialty Insurance Corporation (Special Risks)

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Completed 9 July 2021

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