Family Child Care Insurance Application Military

Military Child Care Provider Application for Insurance
Complete all information. Please print clearly or type. (You may print this form on your own printer. Click File, then Print, then OK.)

**The above Application for Insurance is for *Military* Child Care Providers**
(See below for prices and instructions.)
Name:		Phone (area code):
Address of Licensed Site:		E-mail address:
City:		State:	Zip:
License Number: Effective Dates:	Branch of Military and Base:		Number of Children Currently Enrolled: [ ]
Has your license ever been revoked or suspended?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 pets? (circle one) YES NO If yes, describe (if dog, include breed or mix of breed):
SELECT the limit of liability coverage: (check one) Abuse & Molestation Coverage $100,000 per occurrence, $100,00 per aggregate limit. Coverage for Animal Injury $25,000 per occurrence, $50,000 aggregate limit. * $10,000 Accidental Death & Dismemberment Coverage Optional if licensed in government owned or leased housing and/or not caring for civilian children	[ ] $300,000 Liability		CHECK ONE [ ] Full Premium (Annual) [ ] Payments
	[ ] $500,000 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 choose the payment plan.			$
ENTER the premium amount, from below, if you wish to purchase Accident coverage. Accident coverage is optional unless you are licensed in civiliam housing.			$
ADD "Child Care Services System" Membership Fee ($39.00 per year) Membership is required.			$
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 as a Family Day Care or Group Family Day Care Provider by a branch of the United States Armed Forces. 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 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 suspecion.
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:

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, and equipment exchange opportunities. 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 by military authority 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 premium or payment. (Membership is required for eligibility in the group insurance program.)

MILITARY GROUP RATES* Rates Effective August 1, 2002

MAXIMUM LIMITS AVAILABLE *Includes Maximum $10,000 Accidental Medical Expense, Accidental Death, and Accidental Dismemberment Coverage, optional
FULL PREMIUM 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.
TYPE OF COVERAGE	ONE YEAR PERMIUM (Annual)
	$300,000 Liability		$500,000 Liability		$1,000,000 Liability
	In full	**Payments	In full	**Payments	In full	**Payments
LIABILITY	$168	$28	$186	$31	$204	$34
*OPTIONAL ACCIDENT COVERAGE: ADD**	$36	$6	$36	$6	$36	$6
FULL PREMIUM OR FIRST PAYMENT PLUS SERVICE CHARGE DUE UPON ENROLLMENT **There is an additional $6.00 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