Congregations Caring for Children

Insurance Coverage Questionnaire

Insurance Coverage Questionnaire

Insurance Coverage Questionnaire

Insurance Coverage Questionnaire

Insurance Coverage Questionnaire

Not all insurance programs provide the same coverages. This form will enable

you to compare companies   before a claim occurs.

Please check the types of coverage offered by your company.

Type of Policy:

 ___General Liability

 ___Errors & Omission (Professional Liability)?

Is the Insurance Company Admitted?

___Yes     ___No

Does your insurance program include coverage for:

1

Provider, employees, and all residents of household

(employed in day care or not) as Insureds.

2

Child Abuse defense and indemnity for all insureds per #1 above

(includes legal expense and payment of judgment to policy limit)

3

Child Abuse coverage limit

4

Child Abuse covers sexual, physical, or mental abuse

5

Infants under 6 weeks

6

AIDS/HIV and infectious bodily fluids

7

Off premises/field trips

8

Products/Completed Operations (Food Preparation)

9

Incidental Malpractice (Dispensing Medicine)

10 Personal Injury (Libel, Slander, etc.)

11 Contractual Liability (Including Client Contracts)

12 Transportation coverage

13 Non owned auto coverage

14 Deductibles

15 Swimming Pools/Spas/other bodies of water

16 If no, can it be added?

17 Dogs

18 Extended days or hours that are beyond

regular operations (non emergency)

19 Is there a time limitation to report claims

(other than when known)

Accident: Please indicate Accident Medical Coverages:

20 What is the limit per child, per accident

21 Is it a separate policy?

22 Are field trips covered?

23 Is transportation coverage included?

24 Is the coverage for children primary (pays first)?

25 Is the coverage primary (pays first) (providers

enrolled children covered on excess basis)?

26 Deductibles

Completed by: ____________________________

Title: __________________

Company:        ____________________________

Date: __________________

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