| Name * |
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| E-mail Address * |
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| Address * |
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| City, Zip Code * |
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| Business Phone Number |
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| Please provide us with the number of years you have been in the childcare business |
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| If registered are you a catagory: * |
A
B
C
Not an Iowa Registered Provider
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| Please list your current insurance carrier: |
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| Maximum number of children you watch during each day: |
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| Number of children your Iowa Registration allows you to care for |
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| Preferred liability limit: |
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| Type of Childcare Facility * |
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| Important liability coverage I would like included in proposal: |
Abuse and Molestation
Animal Liability
On or off premises water activities
Abduction liability coverage
All of the above
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| Our business will need coverage for our building and/or business property |
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| How did you find our website? * |
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| In addition to childcare liability I will be requesting coverage for: |
Business Auto
Commercial Umbrella
Both
None
We should talk about this
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| How may we contact you? * |
Telephone
Email
Either Telephone or Email
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| If insured in the past, have you personally or your business ever been cancelled due to claims? |
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| You can save an additional 10% on your home and auto insurance coverages if your daycare insurance is placed with us.... would you like a quote for your auto and home insurance in the event we write your daycare insurance coverage? |
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| Please provide us any additional details that you deem pertinent to your business |
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| How did you find www.IowaDayCareInsurance.com? |
Newspaper Advertisement
Mailing Advertisement
Internet Search
Referred from another daycare provider
Hasn't everyone heard of www.IowaDayCareInsurance.com?
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| This coverage is for Iowa Daycare Providers only.... |
Yes, that is obvious.
I am not from Iowa, but enjoy completing internet forms for absolutely no reason.
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