Child Care Provider Application for Insurance -- California -- Complete all information.  Please print clearly or type.             (You may print this form on your own printer.  Click File, then Print, then OK.)
Name:  Phone (area code): 
Address of Licensed Site: E-mail Address:
City:  State:  California  Zip:                           
License Number:  
Effective Dates:                  		   Type of License:  [   ] 1 to 8     [    ]  7 to 14
Are you currently renting? (circle one)   YES    NO   Landlord's Name: Landlord's Address
Has your license ever been revoked or suspended?  
(circle one)     YES    NO         If yes, explain:		 Number of years of
experience in child care?
In the past five years, have any liability claims or lawsuits been filed against you?   (circle one)   YES   NO  
        If yes, explain.
Has any insurance on your Child Care operation been canceled or not renewed?   (circle one)   YES  NO  
        If yes, explain:
Do you own a pet?  (circle one)   YES  NO   If yes, derscribe (if dog, include breed or mix of breed):
Level of Insurance 
(Select One):		 Small Home
1 to 8  CHILDREN 		Large Home
7 to 14  CHILDREN 		 
SELECT the limit of coverage:
* All include $10,000 Accidental Death & Dismemberment Coverage, Abuse & Molestation Coverage, $100,000 per occurrence, $100,000 aggregate limit. Coverage for Animal Injury $25,000 per occurrence, $50,000		 [    ] $300,000 Liability [    ]$300,000 Liability
[    ] $500,000 Liability [    ] $500,000 Liability
[    ] $1,000,000 Liability [    ] $1,000,000 Liability
ENTER the premium amount, from the tables below, for the coverage selected. $
ENTER service charge of $6.00, if you chose the payment plan. $
ENTER optional non-owned auto premium of $40.00 for one year. $
ADD "Child Care Services System" Membership Fee ($39.00 per year) * Membership is required.  Enter Membership Number #____________________     Valid thru____________________ $
TOTAL AMOUNT ENCLOSED  $
EFFECTIVE DATE OF INSURANCE REQUESTED  
List "Community Partner" (optional, see page below for details):
Coverage effectiveness is based on the Applicant being licensed under the regulations of the Department of Social Services in the State of California. All premiums charged for these programs are based on Membership in the "Child Care Services System" of Adults & Childrens Alliance. I understand and acknowledge that I will receive a Certificate of Insurance (within 4 to 6 weeks from effective date) evidencing coverage provided me as a participant on the policy issued to Adults & Childrens Alliance, Inc. and that the full premium or payment is due upon enrollment. I certify that the information and statements on this form are true and correct to the best of my knowledge. Coverage void if license revoked or operating under suspension.
Signature:  Date: 
Send check and application to:  
Adults & Childrens Alliance  
2885 Country Drive, Suite 165  
Saint Paul, MN 55117-2621
FOR OFFICE USE ONLY
Date Received: 
 		 Date Effective: 
 
The above Application for Insurance is for California Child Care Providers 
(See below for prices and instructions.)
 
 
   A good insurance program will cover you for a variety of situations. These include bodily injury; property damage; accidents on field trips; coverage for you, your children and your substitute Providers; and, the ability to name your landlord as an additional insured for no extra cost. 

   Of course, you also need to consider cost, eligibility requirements and other services. The ACA program was developed to be price competitive. Membership in the Child Care Services System also provides the latest news and information about Child Care, products and resources to help you manage your facility, member discounts, equipment exchange opportunities and substitute care services. The above checklist will help you evaluate Child Care insurance programs. With it, choosing your coverage can be as easy as A-B-C.  
   *You must be licensed to qualify.

 COMMUNITY CHILD CARE PARTNERSHIP 

   To better serve our Members, a portion of our fees are used to support and assist state and local child care associations and organizations to address specific needs in their communities. 
   You, as a member, may designate which association or organization participating in the Alliance "Community Partnership" program you wish to support. Please list your selection (choose only one) in the space provided on the application.  If you are unsure whether your selection is a program participant, you may contact them or the Alliance office. 
   (If your association or organization is not currently a participant and would like more information, please contact the Alliance office.)
Important: To ensure your application is complete , please use the following checklist to assist you in applying (missing information may cause a delay in coverage). 
[  ] Complete all questions.   [  ] Select desired coverage.   [  ] Sign and date your application. 

[  ] Include Membership Fee, (unless your membership is valid for the full term of your new policy). 

[  ] Enclose full payment.  (Membership is required for eligibility in this group insurance program.)
 

CALIFORNIA GROUP RATES*  ANNUAL PREMIUMS
Rates Effective August 1, 2002

TYPE OF LICENSE MAXIMUM LIMITS AVAILABLE
*Includes Maximum $10,000 Accidental Medical Expense, Accidental Death, and Accidental Dismemberment Coverage, plus
FULL PREMIUM DUE UPON ENROLLMENT
OR FIRST PAYMENT PLUS SERVICE CHARGE DUE UPON ENROLLMENT
If you choose the payment installment plan, you need to pay the first payment as listed below. You will
be billed for five payments, one every 30 days. A $6.00 service change applies to each payment.
$300,000 LIABILITY $500,000 LIABILITY $1,000,000 LIABILITY
In full **Payments In full **Payments In full **Payments
Small Home
1-8 Children 		$354 $59 $408 $68 $558 $93
Large Home
7-14 Children 		$576 $96 $714 $119 $936 $156
** There is an additional $6 service charge for each payment. Rates subject to change.

Rev. 07-31-02 |  Return to Insurance Page  | Return to Description and Terms | Application Package via Standard Mail