daycare supp rou026 201104
8417 Patterson Avenue Richmond, Virginia 23229 Telephone: (804) 741-7999 WATTS: (800) 628-2967 Fax: (804) 741-9401 www.royaloakunderwriters.com
ROYAL OAK UNDERWRITERS, INC. Excess and Surplus Lines Insurance Wholesalers
SUPPLEMENTAL DAY CARE APPLICATION (Attach to Commercial General Liability Application)
APPLICANT NAME Address Telephone Number Is applicant an in-Home Daycare Provider? No Yes (Attach Homeowner Declarations) State License Number Years at this location Maximum number of children permitted by License On Site at any given time Indicate number of children in each age group and number of attendants for each group AGE Under 2 Years 2 Years and Up
# OF CHILDREN
# OF ATTENDANTS
Number of Full Time Staff Number Licensed Number of Part Time Staff Number Licensed List Qualifications below: (If additional staff, attach qualifications to application) Name
Years of Experience
Degree
Is any specialized care given (Handicap, Deaf, etc.) Yes No What are the days and hours of operation Are meals served? Yes No If yes, % Prepackaged What type of cooking equipment Type of fire protection for cooking equipment If Ansul system, how often serviced No Do children have access to cooking area Yes Number of floors in Building On which floor is facility Number of rooms in facility Number of Exits on each floor Number and location of smoke detectors Play area fenced Yes No Type of playground equipment Type of surface under playground equipment How often and by whom is playground equipment checked Are there any trampolines of swimming/wading pools How often does the insured schedule trips off premises? How often, to where and furthest distance?
Reset Form rou026-201104
Page 1 of 1
Yes
Submit by E-mail
% Cooked
No
Print Form
SAVE
Royal Oak Underwriters, Inc.
ROYAL OAK UNDERWRITERS, INC. Excess and Surplus Lines Insurance Wholesalers
SUPPLEMENTAL DAY CARE APPLICATION (Attach to Commercial General Liability Application)
APPLICANT NAME Address Telephone Number Is applicant an in-Home Daycare Provider? No Yes (Attach Homeowner Declarations) State License Number Years at this location Maximum number of children permitted by License On Site at any given time Indicate number of children in each age group and number of attendants for each group AGE Under 2 Years 2 Years and Up
# OF CHILDREN
# OF ATTENDANTS
Number of Full Time Staff Number Licensed Number of Part Time Staff Number Licensed List Qualifications below: (If additional staff, attach qualifications to application) Name
Years of Experience
Degree
Is any specialized care given (Handicap, Deaf, etc.) Yes No What are the days and hours of operation Are meals served? Yes No If yes, % Prepackaged What type of cooking equipment Type of fire protection for cooking equipment If Ansul system, how often serviced No Do children have access to cooking area Yes Number of floors in Building On which floor is facility Number of rooms in facility Number of Exits on each floor Number and location of smoke detectors Play area fenced Yes No Type of playground equipment Type of surface under playground equipment How often and by whom is playground equipment checked Are there any trampolines of swimming/wading pools How often does the insured schedule trips off premises? How often, to where and furthest distance?
Reset Form rou026-201104
Page 1 of 1
Yes
Submit by E-mail
% Cooked
No
Print Form
SAVE
Royal Oak Underwriters, Inc.
