To have an agent contact you regarding Childcare Insurance, please complete the short form below.
Childcare Facility Name:
Contact Name:
Phone: (xxx-xxx-xxxx):
FAX: (xxx-xxx-xxxx):
Street Address: *
City: *
County: Choose Greenville Spartanburg Laurens Anderson
State: South Carolina
E-Mail Address: *
Current Insurance Provider:
Have there been an insurance claim in the last 3 years? Yes - No
Number of Infants:
Number of 2 Year Olds:
Number of 3 Year Olds:
Number of 4 Year Olds:
Number of After School Children:
Building Coverage Amount: ,000
Content Coverage Amount: ,000
Construction: Choose 60% or More Brick 60% or More Frame Stucco Cinder Block Log Other
Driver Name:
License Number:
Date of Birth:
Federal ID Number:
Payroll:
* Required Fields
