Specially-Built MySchool Insurance Programs

Name of Childcare

Contact Name

Phone

Email

Date

Member of

ADCO
CCMA
OFIS
OAICC

Note: MySchool Insurance Program insures licensed daycares and private schools.

Address of Operations

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Building Ownership

Owner
Tenant

Physical construction of building childcare occupies :

a) Fire Resistive

Yes
No

(Concrete walls, roof and floors. i.e. high rising building)

b) Masonry non-combustible

Yes
No

(i.e. Stone church, industrial strip mall, public school)

c) Masonry

Yes
No

(Masonry brick, wood floors and roof i.e. churches, built purpose)

d) Brick veneer

Yes
No

Building details

Year Built

Number of Storeys

Total Area Occupied

Hydrant Protected

Yes
No

Current insured values (in $):

The value of your building

The value of the contents, tenants improvement & playground

General liability limit

Director & Officers liability limit

Errors & Omissions liability limit

Enrollment

No. of full time children in your care

No. of part time children in your care

Do you provide transportation for your children?

Yes
No

Staffing

No. of full time employees

No. of part time employees

Revenue

Annual Revenue

Existing Insurance company & Renewal Date

Consent

I consent to the use of this information for quoting purposes

Comments