Child Care Program Information Form Primary Information: *First Name: *Last Name: *E-mail Address: *Daytime Phone: Evening Phone: Best Time to Call: Address (Street): Address (Street 2): City: State: ZIP: County: Daycare Information Inside or Outside City Limits: <CHOOSE> Inside City Limits Outside City Limits Years in Child Card Business Licensed for (#): Hours of Operation: In own home? Yes No Any Pets? No Yes , List type below: Do children participate in any on-premise or off-premise water activites? No Water Activities On-Premise Wading Pool On-Premise Swimming Pool Off-Premise Pool/Lake with Lifeguard Off-Premise Pool/Lake without lifeguard Trampoline on premises? Yes No Transporting Children? Yes No Prior Childcare Liability insurance? No Yes, NAME: Any claims or complaints? *Required Fields Affiliated Insurance, Inc. is Endorsed by The Minnesota Childcare Association
Child Care Program Information Form
Primary Information:
*First Name:
*Last Name:
*E-mail Address:
*Daytime Phone:
Evening Phone:
Best Time to Call:
Address (Street):
Address (Street 2):
City:
State:
ZIP:
County:
Daycare Information
Inside or Outside City Limits:
Years in Child Card Business
Licensed for (#):
Hours of Operation:
In own home?
Yes No
Any Pets?
No Yes , List type below:
Do children participate in any on-premise or off-premise water activites?
No Water Activities On-Premise Wading Pool On-Premise Swimming Pool Off-Premise Pool/Lake with Lifeguard Off-Premise Pool/Lake without lifeguard
Trampoline on premises?
Transporting Children?
Prior Childcare Liability insurance?
No Yes, NAME:
Any claims or complaints?
*Required Fields
Affiliated Insurance, Inc. is Endorsed by The Minnesota Childcare Association
12805 Highway 55 Suite 212 Plymouth, MN 55441
©2006 Affiliated Insurance Services, LLC
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