PROPOSED EFFECTIVE DATE:   From   To      12:01 A.M., Standard Time at the address of the Applicant

Applicant Is: Individual  Corporation   Partnership    Joint Venture   Limited Liability Company Other 

      Is overnight care provided? ................................................................................................................... No Yes

Is care provided for autistic or special needs children (mentally or physically impaired)? ............................ No Yes

 3. Is applicant licensed?......................................................................................................................... No Yes

License number:

Maximum number of children permitted by license:

4. Maximum number of children on premises at any one time:

5. Average daily attendance:

6.  Indicate the number of children within each age group and the corresponding number of attendants
assigned:

7. Total number of employees:

8. Are criminal background checks completed on employees?.............................................................. No Yes

9. Any previous or pending allegations of sexual or physical abuse?..................................................... No Yes

11. Please describe the play equipment and facilities:

Trampoline?........................................................................................................................................ No Yes

Any inflatables, such as moon bounces or slides, rented or owned? ....................................................... No Yes

Play area fully fenced?.......................................................................................................................... No Yes

 Above-ground  In-ground          Swimming pool?......................................................................... No Yes

Number of pools:

Swimming pool slides or diving boards? ................................................................................................ No Yes

Wading pool (less than 24 inches deep)?............................................................................................... No Yes

Life safety equipment at poolside?........................................................................................................ No Yes

Pool area fenced with self-latching gate?............................................................................................... No Yes

Are the rules posted? .......................................................................................................................... No Yes

Is one of the attendants a certified lifeguard or CPR certified?.................................................................. No Yes

Any natural bodies of water (lakes, rivers, streams, etc.) on property?...................................................... No Yes

Ratio of attendants to children while swimming? to

Are there any animals on the premises?................................................................................................ No Yes

Describe:

Are dogs kept away from children?........................................................................................................ No Yes

Other (describe):

13. Any special classes taught?............................................................................................................... No Yes

14. Is applicant transporting children to and from home and/or school?................................................. No Yes

If yes, who is the auto liability insurance carrier?

Does applicant require the drivers to have auto liability insurance?............................................................ No Yes

16. Please attach a copy of the enrollment form, medical release, hold-harmless, etc., used.

Any medication dispensed?.................................................................................................................. No Yes

If yes, please describe:

17. Does applicant have an accident and health policy covering students? .......................................... No Yes

Carrier:  Policy Number: Policy Term:

18. Are children released only to custodial parent or guardian?............................................................. No Yes

If no, describe authorization procedure:

19. Does applicant have any other business ventures for which coverage is not being requested?........ No Yes

Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.

FRAUD WARNING (APPLICABLE IN TENNESSEE AND WASHINGTON):

It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits.

FRAUD WARNING APPLICABLE IN THE STATE OF NEW YORK:

Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.

APPLICANT'S NAME AND TITLE:

(Must be signed by an active owner, partner or executive officer)

PRODUCER'S SIGNATURE:_____________________________________________________________ Date:___________________