Insurance Service Center DePere - In-Home Child Care Checklist

Client Name*

First NameLast Name

Email Address

Coverage subject to policy limitations and payable in the event of qualified claims.

Questions

How many children do you care for?*

Are any of the children related to you?*

YesNo

If yes, please list their names and relationship to you.

Are you interested in coverage for molestation or abuse? (This would require a business policy)*

YesNo

Do you pick up or drop off the children?*

YesNo

Comments:

Do you provide transportation to or from school?*

YesNo

Comments:

Do you provide transportation to any other events or activities?*

YesNo

Comments:

Do you have any equipment (computers, etc.) that you use for the daycare? If yes, please describe in the comments section.*

YesNo

Comments:

Do you have any employees or volunteers that help with the children?*

YesNo

Comments:

Coverage subject to policy limitations and payable in the event of qualified claims.

I have personally reviewed the answers above. I understand that this checklist is not meant to imply, in any manner, that these are the ONLY items that may be of concern to me. I understand it is my responsibility to advise Insurance Service Center of any special circumstances or insurance needs I may have.

Client Signature*

Date*

MonthDayYear

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