Fillable DAY NURSERIES AND PRESCHOOLS SUPPLEMENTAL APPLICATION (RT Specialty)

Fill Online, Printable, Fillable, Blank DAY NURSERIES AND PRESCHOOLS SUPPLEMENTAL APPLICATION (RT Specialty) Form

Use Fill to complete blank online RT SPECIALTY pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

DAY NURSERIES AND PRESCHOOLS SUPPLEMENTAL APPLICATION (RT Specialty)

On average this form takes 43 minutes to complete

The DAY NURSERIES AND PRESCHOOLS SUPPLEMENTAL APPLICATION (RT Specialty) form is 5 pages long and contains:

  • 3 signatures
  • 18 check-boxes
  • 153 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your RT Specialty forms online.

BROWSE RT SPECIALTY FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Scottsdale Insurance Company
Home Office: One Nationwide Plaza
Columbus, Ohio 43215
Adm. Office: 8877 North Gainey Center Drive
Scottsdale, Arizona 85258
Scottsdale Indemnity Company
Home Office: One Nationwide Plaza
Columbus, Ohio 43215
Adm. Office: 8877 North Gainey Center Drive
Scottsdale, Arizona 85258
Scottsdale Surplus Lines Insurance Company
Adm. Office: 8877 North Gainey Center Drive
Scottsdale, Arizona 85258
1-800-423-7675 • Fax (480) 483-6752
www.scottsdaleins.com
DAY NURSERIES AND PRESCHOOLS SUPPLEMENTAL APPLICATION
(Complete in addition to the ACORD Application)
Applicant’s Name:
Location Address:
Agency Name:
Agent:
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
$250,000 Per Claim/$500,000 Aggregate
In-Home Day Care:
$25,000 Per Claim/$50,000 Aggregate
$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:
GLS-APP-5s (12-13) Page 1 of 5
Submit Here
5. Average daily attendance:
6. Indicate the number of children within each age group and the corresponding number of attendants
assigned:
Age Group Number of Children Number of Attendants
1 to 6 months
7 to 12 months
1 to 3 years
over 3 years to 8 years
over 8 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 18” deep: Number of wading pools 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):
1
3. Describe how injuries and illnesses are handled:
GLS-APP-5s (12-13) Page 2 of 5
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 15 passengers utilized? ................................... Yes No
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 to Oregon.)
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-
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
addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the
applicant.
If yes, explain:
GLS-APP-5s (12-13) Page 3 of 5
NOTICE TO FLORIDA APPLICANTS: Any person who knowingly and with intent to injure, defraud, or deceive any in-
surer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a
felony of the third degree.
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
under 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 AUTOMOBILE FRAUD WARNING: Any person who knowingly and with intent to defraud any insurance
company or other person files an application for commercial insurance or a statement of claim for any commercial or per-
sonal insurance benefits containing any materially false information, or conceals for the purpose of misleading, infor-
mation concerning any fact material thereto, and any person who, in connection with such application or claim, knowingly
makes or knowingly assists, abets, solicits or conspires with another to make a false report of the theft, destruction, dam-
age or conversion of any motor vehicle to a law enforcement agency, the department of motor vehicles or an insurance
company, 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 value of the subject motor vehicle or stated claim for each violation.
NEW YORK OTHER THAN AUTOMOBILE 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 civil penalty not to exceed five thousand dollars
and the stated value of the claim for each such violation.
GLS-APP-5s (12-13) Page 4 of 5
APPLICANT’S STATEMENT:
I have read the above application and I declare that to the best of my knowledge and belief all of the foregoing state-
ments are true, and that these statements are offered as an inducement to us to issue the policy for which I am applying.
(Kansas: 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)
NAME AND PHONE NUMBER OF INDIVIDUAL TO CONTACT FOR INSPECTION/AUDIT:
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.
GLS-APP-5s (12-13) Page 5 of 5
click to sign
signature
click to edit
click to sign
signature
click to edit
click to sign
signature
click to edit
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

DAY NURSERIES AND PRESCHOOLS SUPPLEMENTAL APPLICATION (RT Specialty)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 13 December 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document