Enter the Prospects Information Step 1 of 14 7% Input By*Please SelectAmbassadorRyanRobertReneeReceptionistApplicant InformationApplicant Name* First Last Mailing Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Email* Phone*Do we have permission to send you text updates?* Yes Do we have permission to send you email updates?* Yes Business/Facility Name*Federal Tax ID #Nine Digit Number with a dash (-) after first two digits Ex: 12-3456789Applicant is a....* Individual Partnership Corporation LLC Other (please specify) Please specify why you checked other*Effective Date* MM slash DD slash YYYY Please Make the Effective Date 14 Days from this Date Besides property and General Liability, what other coverages are you seeking?* Auto Workers Compensation Umbrella EPLI (Stand Alone) D&O None Premises InformationIs your billing and mailing address the same?* Yes No Building Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Are there any other locations?*NoYesAddress of Location 2* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Are there any other locations?*NoYesAddress of Location 3* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Are there any other locations?*NoYesAddress of Location 4 Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Are there any other locations?*NoYesAddress of Location 5* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Are there any other locations?*NoYesHow many total locations does the business have?*General InformationHas any policy or coverage been declined, cancelled or non-renewed in the past 3 years? (NOT APPLICABLE IN MISSOURI)* Yes No Please Explain Why Yes*Any past losses or claims relating to sexual abuse or molestation allegations, discrimination, or negligent hiring?* Yes No Please Explain Why Yes*Has there ever been an allegation of sexual abuse made against the applicant?* Yes No Please Explain Why Yes*Does the operation have liability insurance with NSI or West Bend Mutual Insurance Company?* Yes No Please Explain Why Yes*Does the applicant own any buildings with more than 2 apartments at any one covered location?* Yes No Please Explain Why Yes*In the last three years, has the operation had any losses or claims?* Yes No Please Explain Why Yes*States in which the applicant does business?* Missouri Illinois Iowa Indiana Kansas Kentucky Michigan Minnesota Ohio Wisconsin Does the applicant perform any operations, childcare or non-childcare, outside of Iowa, Illinois, Indiana, Kansas, Kentucky, Michigan, Minnesota, Missouri, Ohio, or Wisconsin?* Yes No Please Explain Why Yes*Does the applicant perform any non-childcare operations?* Yes No Please Explain Why Yes*Any Commercial Automobile coverage being quoted or issued by NSI or another carrier?* Yes No Please Explain Why Yes* Prior Insurance InformationWho was your prior carrier?*Eff./Exp. Date* MM slash DD slash YYYY Policy NumberPolicy PremiumLoss HistoryAny prior claims?* No Claims Claims How Many Claims in the Last 5 years?*Please Select12341st Claim Date of Occurrence* MM slash DD slash YYYY Description of Claim #1*Amount Paid Claim #1*Claim Status #1* Open Closed Date of Claim #2* MM slash DD slash YYYY Description of Claim #2*Amount Paid Claim #2*Claim Status #2* Open Closed Date of Claim #3* MM slash DD slash YYYY Description of Claim #3*Amount Paid Claim #3*Claim Status #3* Open Closed Date of Claim #4* MM slash DD slash YYYY Description of Claim #4*Amount Paid Claim #4*Claim Status #4* Open Closed Liability Section: General QuestionsIs the center:* Licensed Certified Registered (Iowa Only) None Please attach a copy of state licenseMax. file size: 39 MB.How many years in business?*In the last 12 months, have any complaints been filed with the Licensing Board against applicant's facility?* Yes No Please explain why yes and provide documentation*Documentation UploadMax. file size: 39 MB.In the last three years, has any of the applicant's licenses been revoked, suspended, or placed under probation?* Yes No Please explain why yes and provide documentation*Documentation UploadMax. file size: 39 MB.How many children is the license for? (Location 1)*How many children is the license for? (Location 2)*How many children is the license for? (Location 3)*How many children is the license for? (Location 4)*How many children is the license for? (Location 5)*Are you licensed/certified for:* Infant Care 24-Hour Care Sick Child Care Before/After School Care K4/K5 Other Service *Note: Grades 1-12 and Home schools are ineligible*What time do you open?What time do you close?Please specify your response: Other*Do you perform a criminal background investigation, including sexual abuse or child abuse related offenses on prospective employees?* Yes No How often are these checks done?*Do you perform a criminal background investigation, including sexual abuse or child abuse related offenses on prospective volunteers?* Yes No How often are these checks done?*Do you currently have a Student Accident Insurance Policy in effect?* Yes No Liability Section: Employee OperationsHow many full-time employees do you have?*How many part-time employees do you have?How many full-time volunteers do you have?How many part-time volunteers do you have?Has there ever been an allegation of sexual abuse made against the employee or volunteer?* Yes No Please explain* Liability Section: Other OccupanciesIs the center located in a:* Private Home Commercial Building School Church Other Please describe*Is your Business covered by a Commercial Insurance Policy or Homeowners?*Please SelectHomeowners Policy CoverageCommercial Policy CoveragePlease provide the name of the homeowner's insurance company*Are there any other occupants in this building?* Yes No Please list all other occupants*Does the applicant own the building?* Yes No Does the insured lease any space to other tenants?* Yes No What is the square footage of the area leased out?*Copies of the Lease AgreementsMax. file size: 39 MB.Are any residential apartments located within this building?* Yes No How many apartments?*Copies of the tenant's HO4 and Lease AgreementsMax. file size: 39 MB. Liability Section: TransportationDoes the applicant provide any transportation of registrants?* Yes No Are children transported in:* Private Vehicles Hired Vehicles Public Transportation Other Please describe*What is the age of the youngest driver?*Do you have a Commercial Auto policy?* Yes No Please provide the name of the company* Liabilities Section: Water ActivitiesDoes the applicant provide any on or off premises water activities?* Yes No Discribe any water activities on the premises:* Pool Wading Pool (2ft or less) Other Please explain the activities*If is there a pool or wading pool, is it fenced?*Please SelectYesNoIf is there a pool or wading pool, is it fenced?* Yes No Is there a diving board?* Yes No Is there a slide?* Yes No Is there a certified life-guard on staff at the premise where the water activities are held?* Yes No Are children allowed to participate in off-premise water activities?* Yes No Please describe*Is written permission obtained from parents for any water activities?* Yes No Please describe* Liability Section: Other ActivitiesIs there a trampoline on the premises?* Yes No Is there any gymnastic equipment on the premises?* Yes No Please describe*Are there any dogs on the premises?* Yes No Please describe the breed and any previous biting history*Are there any other pets or animals on the premises?* Yes No Please describe*Are children allowed contact with any animals?* Yes No Please describe* General Liability Per Occurrence / Aggregate Limits* $1,000,000/$3,000,000 $1,000,000/$2,000,000 $500,000/$1,000,000 $300,000/$600,000 *Note: $10,000 Medical Payment and $200,000 Fire Legal are both included*Do you have any additional insureds?* Yes No Optional Liability CoveragesAbuse and Molestation Coverage- Optional* Yes No Dog and Cat Liability Coverage (In-home centers only)* Yes No Hired and Non-owned Auto Liability Yes No Water Activities- $150,000/$150,000 Limit* Yes No Water Activities On and Off Premises- Policy Limit* Yes No EPLI* Yes No EPLI Limit* 100,000 250,000 Number of Employees*Employee Benefit Liability* Yes No Property Coverages/Building InformationBuilding Coverage Desired?* Yes No Building InformationLocation Number 1Building Number 1Construction* Frame Joisted Masonry NonCombustible Masonry NonCombustible Fire Resistive Total Square Feet of Building*Total Square Feet Leased OutNumber of Stories*% OccupiedProt. ClassAge of BuildingBuilding ImprovementsWiring YearRoofing YearPlumbing YearHeating YearIs the building sprinklered?* Yes No Automatic Commercial Cooking Exhaust and Extinguishing System?* Yes No Feet to fire hydrantMiles to fire stationRoof Surfacing Coverage Limitations:* ACV (Wind/Hail) Exclude Cosmetic Damage (Wind/Hail) Both N/A Limits/ValuationContents* RC ACV Please Enter $ Amount For Contents*Building RC ACV Please Enter $ Amount For BuildingImprovements and Betterments RC ACV Please Enter $ Amount For Improvements and BettermentsProperty Deductible* $2500 $1000 $500 $250 Any Optional Property Coverages* Yes No Computer Coverage, Condominium Unit, Earthquake, Food Contamination, Legal Liability, Outdoor Signs, Money and Securities, Employee Dishonesty Optional Property CoveragesComputer Coverage in excess of $25,000?* Yes No Excess limit:Condominium Unit - Owners Coverage* Yes No Earthquake - Building* Yes No Earthquake - Personal Property* Yes No Food Contamination* Yes No Food Contamination Limit* $75,000 $50,000 $25,000 $20,000 $15,000 $10,000 Legal Liability in Excess of $200,000* Yes No Building Limit:Outdoor Detached Signs in Excess of $10,000* Yes No Sign Excess Limit:Money and Securities* Yes No Inside Premises in Excess of 15,000 Yes No Outside Premises in Excess of 7,000 Yes No Excess Limit for Inside PremisesExcess Limit for Outside PremisesEmployee Dishonesty* Yes No Limit:* $25,000 $10,000 Is there a written return to work program in place, to encourage/assist employees in rejoining the workforce?* Yes No Return to Work PolicyMax. file size: 39 MB.
