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WE OFFER QUALITY INSURANCE PRODUCTS, WE ARE NOT THE CHEAPEST, IF YOU WANT QUALITY INSURANCE COVERAGE, PLEASE PROCEED.

For help filling out the quote form, please call our In-Home agent, Stephanie Spencer directly at 1-800-273-4510.

Please take a moment to fill out this Quick Quote Form for a In-Home Business Owner Policy. This information is used for rating only and held in strict confidence.
Business Information
Business Name:
Owners Name
E-mail Address
Physical Address
Mailing Address
City
County:
State
Zip
Phone
Proposed Effective Date
Property Information
Facility located in a mobile home?
 
Facility located in an Apartment?
 
Facility located in a Duplex?
 
Desired amount of day care equipment coverage:
Building Construction:
(check all that apply)
Frame
Masonry
Non-Combustible
Fire Resistant
Building Age:
Year of last update:

Heating
Plumbing
Electrical
Roof

Condition of Building
Business is conducted in a:

Is there a playground or yard?
 
If YES, please decribe playground equipment:
If YES, is this playground or yard fenced?
 
If YES, does this fence have self-closing devices?
 
Do you have emergency transportation available?
 
Do you utilize swimming facilities on or off the premises?
 
If YES, please decribe:
Do you have a swimming pool on premises?
 
Do you accept lodgers in your home?
 
Liability Information
Requested Liability Limits
(includes professional liability & $1,000 property)

$ occurrence

$ aggregate
Maximum number of children on premises at one time (if montessori or pre-school)
Maximum number of children you are licensed to care for at one time:
Number of enrolled children Birth to 18 months:
Large trampoline on premise?
 
Any pets on premise?
 
If yes, list number and breed:

If yes, are the pets separated from the children?
 
Are there any children enrolled who are emotionally or physically handicapped, or require special care due to a medical condition?
 
If YES, please explain the condition(s)and number of children who fit this description:
Number of off premises field trips per year:
Where to and what mode of transportation?
Any overnight care provided?
(Overnight is defined as being open more than 14 hours)
(If YES, Sexual Abuse & Professional Liability Coverages are NOT available)

Hours of operation Weekdays:
Hours of operation Weekends:
AM to PM
AM to PM
Coverage Requested
Liability Limits
(includes professional liability & $1,000 property)
$
Sexual abuse liability?
 
Higher limits of property desired?
Additional Insured
 
If yes, name and address:
Dog Bite Coverage?
($50,000 limit for $75.00)
 
Swimming Pool Coverage?
 
Wading Pool Coverage?
 
Almost Done!
Licensing Agency:
Number of Years Licensed:
Owners related experience and education:
Is there a pre-employment background check (including personal references, police record, education, physical/emotional testing)?
 
Current Insurance Carrier:
Total annual insurance premium:
$
Renewal being offered?
 
If NO, please explain:
Renewal date
/
Any claims in the past five years?
 
If YES, please explain (with dollar amounts):
   
Best time to contact me is:
I hereby declare to the best of my knowledge and belief that all of the foregoing statements are complete and true and that these statements are offered as an inducement to the company to issue the policy for which I am applying. It is understood and agreed that the completion of this questionnaire does not bind the insurance company.