Fillable COLONY INSURANCE COMPANY COLONY SPECIALTY INSURANCE COMPANY PELEUS (Strickland Insurance Brokers)

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COLONY INSURANCE COMPANY COLONY SPECIALTY INSURANCE COMPANY PELEUS (Strickland Insurance Brokers)

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The COLONY INSURANCE COMPANY COLONY SPECIALTY INSURANCE COMPANY PELEUS (Strickland Insurance Brokers) form is 3 pages long and contains:

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  • 61 check-boxes
  • 32 other fields

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File type: PDF

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C‐APP010‐0815 Page1of3
COLONY INSURANCE COMPANY – COLONY SPECIALTY INSURANCE COMPANY
PELEUS INSURANCE COMPANY
CONTRACT DIVISION – DAY CARE - SUPPLEMENTAL APPLICATION
ACORD Application also required - Check all applicable checkboxes below
General Agent:
Date:
Insured:
Insured Mailing Address:
Insured’s Web Address:
Insured Contact Name:
Phone Number:
PROHIBITED (check all that apply to your operations)
Adult day care
Animals on premises
Developmentally disabled or handicapped day care
Drop-In day care
Exercise equipment
Gymnastics lessons
Medical related day care
Nurse or other licensed health practitioner in applicant’s employment
Swimming pools on premises
Trampolines
YEARS IN BUSINESS / EXPERIENCE
_____ Years in business as the ‘Named Insured’ indicated on this application
_____ Years’ experience in the operations indicated on this application - Attach resumes if available
Has applicant had an insurance policy cancelled or non-renewed in past 3 years? If yes, explain.
(Missouri Applicants - Do not answer this question)
Applicant in receivership
Bankruptcy (Chapter 7, 11 or 13) has been filed in past 5 years
LICENSING
Licenses and certifications, as required by state and/or locality are all in place
License Number: ____________________________________________
LOSS HISTORY
Three years of loss history information provided on ACORD application or attached to this application
C‐APP010‐0815 Page2of3
DAY CARE - SUPPLEMENTAL APPLICATION
OPERATIONS / EXPOSURES / CONTROLS
Commercial day care operation
In-home day care operation
Homeowners Insurance in force
Nanny
OPERATIONS / EXPOSURES / CONTROLS
Age Groups:
Age Group # of persons in this Age Group # of Attendants for this Age Group
Birth to 6 months
16 months to 2 years
2 and 3 year olds
4 year and 5 year olds
6 years and older
Field Trips:
_______ Number of field trips per month on average
Permission slips (signed) are required in order to go on field trip
Trips may include visits to a beach, lake or swimming pool
Trips may include visits to amusement facilities
Trips may include visits to zoos
Trips to destinations not listed above include (describe below):
Medical:
Health records are obtained for each child that is enrolled including immunization records and dietary issues
Immunization records obtained for each child enrolled
Medicines and first aid equipment are stored out of reach of children
Overnight:
Overnight or Over-stay services offered
Premises:
Carbon monoxide detectors in place
Doors are equipped with panic bars
Exits clearly marked, lighted and free of obstructions
Fire extinguishes on premises and have current inspection tags
Medicines and first aid equipment are stored out of reach of children
Playground equipment (describe): __________________________________________________________
Play area(s) if outdoors are fully fenced with self-locking gates
Play area(s) if outdoors have an artificial soft-surface material installed
Smoke detectors in place Battery Hardwired
SUBCONTRACTORS / INDEPENDENT CONTRACTORS
Uninsured subcontractors are not acceptable
Risk Transfer – Subcontractors:
Additional Insured – Status granted to you on the subcontractor’s policy
Certificates of Insurance - Always obtained from a subcontractor prior to any work being done for you
Limits of Liability - Subcontractors are required to carry limits equal or above your own
EMPLOYEES
Criminal background checks performed on all employees At time of hire only Annually
CPR trained staff member (at least one) is always on duty during hours of operation
Drug testing of all employees
C‐APP010‐0815 Page3of3
DAY CARE - SUPPLEMENTAL APPLICATION
RATING BASIS
All Operations
$
Number of Children
Number of Days per Week
PLANNED EXPANSION OR NEW ACTIVITIES IN COMING POLICY TERM
New activities or expansion is anticipated (describe):
COVERAGE OPTIONS - LIABILITY (check if you would like an optional quote on any of the following)
Employee Benefit Liability – U058
Employment Practices Liability Insurance – U817 (Not available in AR, LA, MT, NM, NY, VT)
High Limits General Liability
Identity Recovery – i.e. Identity Theft – U651
Medical Expense Limit of $10,000 rather than $5,000
Stop Gap Liability – U066
COVERAGE OPTIONS - PROPERTY (check if you would like an optional quote on any of the following)
Building Ordinance or Law (Increased Cost of Construction) – U750
Equipment Breakdown – U522 & U523
Property Coverage Enhancement: Bronze – U777C, Silver – U777B or Gold – U777A
Signs (Outdoor) – CP1440
Water Back Up and Sump Overflow – U548
GENERAL FRAUD STATEMENT (Not applicable in all states.)
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, may be committing a fraudulent insurance act, and may be subject to
a civil penalty or fine.
The undersigned is an authorized representative of the applicant and certifies that reasonable inquiry has been made to
questions on this application. He/She certifies:
The answers are true, correct and complete to the best of his/her knowledge.
They agree to the Privacy and Fraud provisions found in the ACORD-125 (Commercial Insurance Application)
and understand those provisions also apply to this supplemental application.
SIGN AND DATE
PRODUCER’S SIGNATURE DATE
APPLICANT’S PRINTED NAME DATE
APPLICANT’S SIGNATURE DATE
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COLONY INSURANCE COMPANY COLONY SPECIALTY INSURANCE COMPANY PELEUS (Strickland Insurance Brokers)

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Completed 17 July 2021

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