|| Hylant Group - Insurance, Risk Management, Consulting ||

If you would prefer to speak with an agent instead of completing this online form, please call Hylant Group of Ann Arbor at 734-741-0044 or Brett Redington at 734-662-1710. All fields are required for an accurate quote otherwise an agent will need to contact you for additional information. Thank you!

General Information

Business Name:	Contact Person:
Address #1:	Address #2:
City:	State:	Zip:
Daytime Phone:	Evening Phone:
Fax:	E-mail Address:
Current Carrier:

Premises Information

Location Number

Building Number

Street, City, County, State, Zip

Underwriting

Years in Business:

Do you own or rent your location?

Have there been any losses or allegations of sexual abuse made against you?

Are you licensed?

Have you had any complaints to the licensing board in the last 12 months?

How many children are you licensed to care for?

Location Number 1

Location Number 2

Location Number 3

Are you certified for:

Infant Care

24 Hour Care

Sick Child Care

Before/After School

K4/K5

Other

Hours of operation? AM to PM

Number of Employees:

Full Time

Part Time

Located In?

Private Home

Commercial Building

School

Church

Other

If located in commercial building? Any other occupants in building?

Do you own the building?

Do you provide transportation?

Do you have a Commercial Auto policy in place?

Is there a pool on premises?

Is there dogs or other animals on premises?

Building Information

Coverage Desired?

Construction:

Year Built:

Square Feet:

Number of Stories:

Percent Occupied:

Sprinklered

Updates:

Heat

Plumbing

Electricity

Roof

Limits

Building Value:

Contents Value:

Please note that no coverage can be bound, changed, or deleted via this web site. You may make a request.
However, any request is not deemed effective until a formal verification is sent to you from our office.