Church Insurance Application

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

    Church Info

    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

    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

    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

    Property Info

    Buildings

    List which buildings include the following and provide its age:

    Roof

    Electrical

    Plumbing

    Heating & A/C

    If not on all buildings please list which buildings:

    Do you have a monitored alarm system on all buildings?

    BurglarFireLocal(not reporting to any agency)

    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:

    Other Info: Does any of the following apply

    Camps?

    Music Schools?

    Fund Raising?

    Dormitories?

    Athletics?

    Traveling Ministry?

    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

    Your Name*

    Your Email*

    Fields marked with an * are required