FAMILY CHILD CARE PROVIDER APPLICATION FOR INSURANCE

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• THIS PAGE IS FOR NEW MEMBERS WHO DO NOT CURRENTLY HAVE COVERAGE OR MEMBERSHIP WITH ASSURE CHILD CARE. IF YOU WOULD LIKE TO RENEW YOUR EXISTING POLICY OR MAKE A PAYMENT, PLEASE CLICK HERE TO LOG-IN TO THE PROVIDER SERVICE CENTER.

• BY COMPLETING & SUBMITTING MY APPLICATION FOR COVERAGE ONLINE, I UNDERSTAND THAT ACC WILL CONDUCT ALL COMMUNICATIONS REGARDING MY APPLICATION, POLICY & PAYMENTS IN ELECTRONIC FORMAT (VIA EMAIL) USING THE ELECTRONIC MAIL ADDRESS INDICATED IN MY APPLICATION. I AGREE TO THE SAME AND GRANT PERMISSION BY SUBMITTING MY APPLICATION ELECTRONICALLY.


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