Morgan & Associates - The Internet's #1 Childcare Insurance Specialist

Morgan Insurance.com

In-Home

WE OFFER QUALITY INSURANCE PRODUCTS, WE ARE NOT THE CHEAPEST, IF YOU WANT QUALITY INSURANCE COVERAGE, PLEASE PROCEED. 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 an Condo?
Facility located in a Duplex?
Business is conducted in a:
Please decribe playground equipment:
Yard fenced?
Do you have a swimming pool on premises?
If YES, please decribe (inground, above ground, diving board, slide?:

Liability Information
Maximum number of children you are licensed to care for at one time:
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?
Hours of operation Weekdays: Hours of operation Weekends:	AM to PM AM to PM

Coverage Requested
Liability Limits
Abuse/Molestation Liability?
Higher limits of property desired?
Additional Insured
If yes, name and address:
Dog Bite Coverage?
Swimming Pool Coverage?
Wading Pool Coverage?

Almost Done!
Licensing Agency:
Current Insurance Carrier:
Total annual insurance premium:	$
Renewal being offered?
If NO, please explain:
Any claims in the past five years?
If YES, please explain (with dollar amounts):

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 Premium Quote for which I am applying. It is understood and agreed that the completion of this questionnaire does not bind the insurance company.