| Proposed Effective Date |
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Company Name |
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Address |
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City |
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State |
Zipcode |
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County |
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Location of address if different than above |
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Contact Name |
Phone Number |
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Address |
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Business Type
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School Type |
| # of years in business | How long has this location been open? Do you operate more than one location? |
| Hours of operation | From AM | TO |
PM |
# of Days per Week | # of Months per Year |
Is the facility licensed by the state? |
List all accreditations. |
Center's location. |
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If owned, what is the building value? |
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| Year Built |
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# of Stories |
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Total Square Footage of Center |
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Construction Type |
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| Amount of contents coverage desired | Total Estimated Annual Payroll |
| Liability Limits Desired | Would you like Abuse and Molestation Coverage to be provided? |
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Abuse and Molestation Limits Desired |
| Have you had an incident which resulted in an allegation of Sexual Abuse? |
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| Do you provide Student Accident Coverage for your students? |
Are criminal investigations conducted on all employees? |
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| Director's Name | Number of years in childcare |
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Specialized Education or Training |
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| Number of Teachers with a degree |
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Number of Teachers without a degree |
| Number of Aides | Are there any other employees? | If yes, Describe. |
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| Are there any employees under 18 years old? | If yes, list position |
| Is there always someone trained in CPR on the premises? |
| Licensed Capacity | Current Enrollment | Average # of Children per day |
| Infants, ages 0-1 | # of Children | # of Staff |
| Toddlers, ages 1-2 | # of Children | # of Staff |
| Toddlers, ages 2-3 | # of Children | # of Staff |
| Preschoolers, ages 3-5 | # of Children | # of Staff |
| School age children | # of Children | # of Staff |
Total # of Children |
Total # of Staff |
| Are special needs children cared for? | If yes, describe their disabilities and any special arrangements made to care for these children |
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| Does the Center have a Playground? | Is the playground fenced? |
| Describe all playground equipment including height. |
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| Describe the surface under the playground equipment | Depth of Surface |
| Do you utilize swimming facilities? |
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| Number of field trips per year |
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Are release forms obtained? |
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| Does facility provide transportation for field trips? |
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If No, how is it provided? |
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| If vehicles are hired, are they hired with a driver |
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| Does facility provide transportation to and from the center? |
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Do employees / volunteers transport children in their own vehicles? |
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If yes, how often? |
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| Does facility own any vehicles? | If yes, do you use the vehicle (s) to transport children |
| Year | Make | Model | VIN # |
| Garaging Location | Gross Vehicle Weight | Vehicle Cost |
| Year | Make | Model | VIN # |
| Garaging Location | Gross Vehicle Weight | Vehicle Cost |
| Are certificates of insurance obtained showing at least $300,000 worth of liability coverage? |
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| Has prior insurance coverage coverage been cancelled or non-renewed? |
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| Has center had any insurance claims within the last 5 years? |
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| Name of current insurance carrier |
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| Expiration Date | Current estimated annual cost of insurance for the center |
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Should you have any problems submitting this form, you may print the form out and Fax it to (800) 329-8309.
You are Visitor
Last updated April 23, 2003