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DAY NURSERIES AND PRESCHOOLS SUPPLEMENTAL APPLICATION (Colonial General Insurance Agency, Inc)

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GL-APP-5s (9-16) Page 1 of 5
DAY NURSERIES AND PRESCHOOLS SUPPLEMENTAL APPLICATION
(Complete in addition to the ACORD Application)
Applicant’s Name:
Location Address:
Agency Name:
Agent No.:
Phone No.:
PROPOSED EFFECTIVE DATE: From To 12:01 A.M., Standard Time at the address of the Applicant
ANSWER ALL QUESTIONS—IF THEY DO NOT APPLY, INDICATE “NOT APPLICABLE” (N/A)
1. Description of operations: Day Care Center Drop-off Center Before/After School Program
In-Home Day Care Sick-Child Day Care Foster Care
Part of an Organization (describe):
How long has applicant been in business? .................................................................................................
Is overnight care provided? ......................................................................................................................... Yes No
Is care provided for autistic or special needs children (mentally or physically impaired)? .......................... Yes No
Is facility open twenty-four (24) hours a day? .............................................................................................. Yes No
If risk is a drop-off center, is it located at a shopping mall or other retail establishment? ........................... Yes No
Does applicant provide nannies or similar services away from premises address above? ........................ Yes No
2. Sexual and/or Physical Abuse Coverage Limits:
Day Care Centers:
$100,000 Per Claim/$300,000 Aggregate (included)
$250,000 Per Claim/$500,000 Aggregate
In-Home Day Care:
$ 25,000 Per Claim/$ 50,000 Aggregate (included)
$ 50,000 Per Claim/$100,000 Aggregate
$100,000 Per Claim/$300,000 Aggregate
3. Is applicant licensed, registered and/or in compliance with state regulations? ................................ Yes No
License number (if applicable):
Maximum number of children permitted by license/regulations: .................................................................
4. Maximum number of children on premises at any one time: ...............................................................
5. Average daily attendance: ........................................................................................................................
GL-APP-5s (9-16) Page 2 of 5
6. Indicate the number of children within each age group and the corresponding number of attendants as-
signed:
Age Group Number of Children Number of Attendants
One to Six Months
Seven to Twelve (12) Months
One to Three Years
Over Three Years to Eight Years
Over Eight Years
7. Total number of employees: .....................................................................................................................
8. Are criminal background checks completed on employees? .............................................................. Yes No
9. Any previous or pending allegations of sexual or physical abuse? .................................................... Yes No
10.
Building Description (age, construction, exits, etc.):
11. Are there any bottle warmers and/or cooking appliances located in areas where children could
access? ....................................................................................................................................................... Yes No
12. Play Equipment and Facilities:
Are there trampolines? ................................................................................................................................ Yes No
Are there inflatables, such as moon bounces or slides, rented or owned? ................................................. Yes No
Is the play area fully fenced? ....................................................................................................................... Yes No
Are there swimming or wading pools?......................................................................................................... Yes No
If yes:
Number of pools over eighteen inches (18”) deep: ...............................................................................
Number of wading pools eighteen inches (18”) or less: ........................................................................
Are swimming pools located: Above-ground In-ground
Are there swimming pool slides or diving boards? ............................................................................... Yes No
If yes, advise height: .............................................................................................................................
Is life safety equipment at poolside? ..................................................................................................... Yes No
Is pool area fenced with self-latching gate? .......................................................................................... Yes No
Are rules posted? .................................................................................................................................. Yes No
Is a certified lifeguard or CPR certified attendant present at all times? ................................................ Yes No
What is the ratio of attendants to children while swimming? to
Are all swimming pools, wading pools, hot tubs and spas in compliance with the federal Virginia
Graeme Baker Pool and Spa Safety Act? ............................................................................................. Yes No
Are there any natural bodies of water (lakes, rivers, streams, etc.) on the property? ................................. Yes No
Are there animals on the premises? ............................................................................................................ Yes No
If yes, describe:
Are dogs kept away from children? ............................................................................................................. Yes No
Other (describe):
GL-APP-5s (9-16) Page 3 of 5
13.
Describe how injuries and illnesses are handled:
14. Any special classes taught (i.e., dance, gymnastics, martial arts, etc.)? ................................................. Yes No
If yes, describe:
15. Is applicant transporting children to and from home and/or school? ................................................. Yes No
If yes, who is the auto liability insurance carrier?
16. Are any vehicles with a seating capacity exceeding fifteen (15) passengers utilized? ..................... Yes No
If yes, explain:
17.
Describe the nature of any field trips (number of trips, who transports, etc.):
Does applicant require the drivers to have auto liability insurance? ........................................................... Yes No
18. Attach a copy of the enrollment form, medical release, hold-harmless, etc., used:
Any medication dispensed? ......................................................................................................................... Yes No
If yes, describe:
19. Does applicant have an accident and health policy covering students? ............................................ Yes No
Carrier: Policy Number: Policy Term:
20. Are children released only to custodial parent or guardian? ............................................................... Yes No
If no, describe authorization procedure:
21. Does risk engage in the generation of power, other than emergency back-up power, for their
own use or sale to power companies?.................................................................................................... Yes No
If yes, describe:
22. Does applicant have any other business ventures for which coverage is not requested? ............... Yes No
If yes, explain and advise where insured:
This application does not bind the applicant nor the Company to complete the insurance, but it is agreed that the infor-
mation contained herein shall be the basis of the contract should a policy be issued.
FRAUD WARNING: 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 applicable in AL, CO, DC, FL, KS, LA, ME, MD, MN, NE, NY,
OH, OK, OR, RI, TN, VA, VT or WA.)
NOTICE TO ALABAMA APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a
loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be
subject to restitution fines or confinement in prison, or any combination thereof.
NOTICE TO COLORADO APPLICANTS: It is unlawful to knowingly provide false, incomplete, or misleading facts or in-
formation 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 policy holder or claimant for
the purpose of defrauding or attempting to defraud the policy holder or claimant with regard to a settlement or award pay-
GL-APP-5s (9-16) Page 4 of 5
able from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory
Agencies.
WARNING TO DISTRICT OF COLUMBIA APPLICANTS: It is a crime to provide false or misleading information to an
insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addi-
tion, an insurer may deny insurance benefits if false information materially related to a claim was provided by the appli-
cant.
NOTICE TO FLORIDA APPLICANTS: Any person who knowingly and with intent to injure, defraud, or deceive any insur-
er files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a fel-
ony of the third degree.
NOTICE TO KANSAS APPLICANTS: Any person who, knowingly and with intent to defraud, presents, causes to be pre-
sented 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 state-
ment 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 con-
ceals, 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.
NOTICE TO LOUISIANA APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a
loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be sub-
ject to fines and confinement in prison.
NOTICE TO MAINE APPLICANTS: 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.
NOTICE TO MARYLAND APPLICANTS: Any person who knowingly or willfully presents a false or fraudulent claim for
payment of a loss or benefit or who 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.
NOTICE TO MINNESOTA APPLICANTS: A person who files a claim with intent to defraud or helps commit a fraud
against an insurer is guilty of a crime.
NOTICE TO OHIO APPLICANTS: Any person who, with intent to defraud or knowing that he is facilitating a fraud against
an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.
NOTICE TO OKLAHOMA APPLICANTS: Any person who knowingly, and with intent to injure, defraud or deceive any
insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading infor-
mation is guilty of a felony.
NOTICE TO RHODE ISLAND APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment
of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be
subject to fines and confinement in prison.
FRAUD WARNING (APPLICABLE IN VERMONT, NEBRASKA AND OREGON): Any person who intentionally presents
a materially false statement in an application for insurance may be guilty of a criminal offense and subject to penalties un-
der state law.
FRAUD WARNING (APPLICABLE IN 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. Penal-
ties include imprisonment, fines, and denial of insurance benefits.
NEW YORK FRAUD WARNING: 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 also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim
for each such violation.
APPLICANT’S STATEMENT:
GL-APP-5s (9-16) Page 5 of 5
I have read the above application and I declare that to the best of my knowledge and belief all of the foregoing statements
are true, and that these statements are offered as an inducement to us to issue the policy for which I am applying. (Kan-
sas: This does not constitute a warranty.)
APPLICANT’S SIGNATURE: DATE:
CO-APPLICANT’S SIGNATURE: DATE:
PRODUCER’S SIGNATURE: DATE:
AGENT NAME: AGENT LICENSE NUMBER:
(Applicable to Florida Agents Only)
IOWA LICENSED AGENT:
(Applicable in Iowa Only)
IMPORTANT NOTICE
As part of our underwriting procedure, a routine inquiry may be made to obtain applicable information concerning
character, general reputation, personal characteristics and mode of living. Upon written request, additional information
as to the nature and scope of the report, if one is made, will be provided.
Agent Email:
Preferred Method of Correspondence Email Fax Mail
Applicant Email:
Preferred Method of Correspondence Email Fax Mail
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DAY NURSERIES AND PRESCHOOLS SUPPLEMENTAL APPLICATION (Colonial General Insurance Agency, Inc)

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Completed 22 August 2020

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