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Church Insurance Application 2017-12-18T16:48:31+00:00

Fill out the below application form to get a free quote on your church insurance.

Church Info

youth group

Do you have a Youth Group ?

YesNo

Note: If you selected 'No' to the above answer, you can skip this section of the application.

Age Range of Children

Number in attendance each week

Who runs the youth group

Include a list of activities that are done

School Info

Does your church have a school?

YesNo

Note: If you selected 'No' to the above answer, you can skip this section of the application.

Date school was founded

Describe security measures taken on premise

Day Care

Is there a Day Care on site?

YesNo

Note: If you selected 'No' to the above answer, you can skip this section of the application.

Age Group

Infants (0-24 months/2yrs)Toddlers (25-36 months/3yrs)Toddlers (37-48 months/4yrs)Pre-K (49-60 months/5yrs)School Age (61 months & Up)

# of children in each age group

Avg. Daily Attendance

Total Staff Breakdown

Church Staff Details

Please fill in the number values for each position if applicable.

Pastors / Ministers

# of Full Time:

# of Part Time:

Custodians

# of Full Time:

# of Part Time:

Office Personnel

# of Full Time:

# of Part Time:

Tech / A/V Personnel

# of Full Time:

# of Part Time:

Counselors

# of Full Time:

# of Part Time:

Nurses

# of Full Time:

# of Part Time:

Total Number of Church Staff

Total Volunteers for Church

Do you have written policies and procedures regarding sexual abuse tolerance and behaviors for staff and volunteers?

School Staff

YesNo/Not Applicable

Note: If you selected 'No' to the above answer, you can skip this section of the application.

School Staff Details

Please fill in the number values for each applicable position.

Administrators

# of Full Time:

# of Part Time:

Nurses

# of Full Time:

# of Part Time:

Teachers K5 to 5th

# of Full Time:

# of Part Time:

Teachers 6th – 8th

# of Full Time:

# of Part Time:

Teachers 9th – 12th

# of Full Time:

# of Part Time:

Counselors

# of Full Time:

# of Part Time:

Total Number of School Staff

Total Volunteers for School

Average Adult to Student ratio including helpers

Day Care Staff

YesNo/Not Applicable

Note: If you selected 'No' to the above answer, you can skip this section of the application.

Day Care Staff Details

Please fill in the number values for each applicable position.

Directors

# of Full Time:

# of Part Time:

Nurses

# of Full Time:

# of Part Time:

Office Personnel

# of Full Time:

# of Part Time:

Teachers 0-24 months

# of Full Time:

# of Part Time:

Teachers 25-36 months

# of Full Time:

# of Part Time:

Teachers 37-48 months

# of Full Time:

# of Part Time:

Teachers 49-60 months

# of Full Time:

# of Part Time:

Teachers School Age

# of Full Time:

# of Part Time:

Total Number of Daycare Staff

Total Volunteers for Daycare

Property Info

Building 1

Name of Building or Use

List approx. age, or year, each of the following was built or last updated:

Roof

Electrical

Plumbing

Heating & A/C

Does this building have a monitored central alarm system?

Does the building have a sprinkler system?

If so, approx. what % of the building has the sprinkler system?

What is the approx. dollar amount of the contents in this building?

Building 2 - Skip this section if not applicable.

Name of Building or Use

List approx. age, or year, each of the following was built or last updated:

Roof

Electrical

Plumbing

Heating & A/C

Does this building have a monitored central alarm system?

Does the building have a sprinkler system?

If so, approx. what % of the building has the sprinkler system?

What is the approx. dollar amount of the contents in this building?

Building 3 - Skip this section if not applicable.

Name of Building or Use

List approx. age, or year, each of the following was built or last updated:

Roof

Electrical

Plumbing

Heating & A/C

Does this building have a monitored central alarm system?

Does the building have a sprinkler system?

If so, approx. what % of the building has the sprinkler system?

What is the approx. dollar amount of the contents in this building?

Business Auto info

Do you require a business auto quote with this application ?

YesNo

Note: If you selected 'No' to the above answer, you can skip this section of the application.

Owned Autos

*Provide the following for each vehicle:

Year:

Make:

Model:

Vin#

Cost New:

Gross Weight:

Vehicle use:

Garaging location:

How many miles one way:

Driver Information

Provide the following for each approved driver:

Full name:

License #

Date of Birth:

State Licensed:

Type and Year of Commercial driver’s license (if any):

Workers' Comp info

Do you require Workers Comp Quote with this application?

YesNo

Note: If you selected 'No' to the above answer, you can skip this section of the application.

Directors & Officers

List of Officers names with the following:

Position:

Title:

Job function:

Estimated payroll:

Include or Exclude from the workers comp:

Total number of employees for church not including the officers?

Total number of employees for school not including the officers?

Total number of employees for day care not including the officers?

Employees(Other than officers)

Position tile:

Full or Part time:

Job function:

Estimated payroll:

Insurance

Information on your current insurance provider?

Name of Company:

Effective Dates:

Premium:

Years in Force:

Have you had any previous insurance claims?

YesNo

If so, please list the following:

Date of Incident:

Dollar Amount of Payout:

Brief Description:

Other Info: Does any of the following apply

Camps?

Music Schools?

Fund Raising?

Dormitories?

Athletics?

International Missions?

Does the church or its members, volunteers, employees, ministers take part in construction projects?

Private Education Info

Private Elementary School

# of Students

# of Teachers

Private Middle School

# of Students

# of Teachers

Private High School

# of Students

# of Teachers

College / University

# of Students

# of Teachers

About You

Your Name*

Your Email*

Your Phone Number*

Fields marked with an * are required