New Church Quote Form

- Step 1 of 7

Legal Name of Church / Organization *

DBA: If Applicable

Your Name *

First

Last

Email *

Phone *

Website / URL

Property Address *

Address Line 1

Address Line 2

City

State

Zip Code

Is Billing Address the Same as Property Address

Mailing Address *

Address Line 1

Address Line 2

City

State

Zip Code

Requested Effective Date *

Are you Currently Insured *

Name of Current Insurance Carrier *

Expiring Insurance Premium

Any Church Insurance Claims (Past 5 Years) *

Please provide details of all claims (Past 5 Years) *

FEIN Number (Federal Identification Number)

Rent or Own *

Number of Members *

Approximate Year Built of Building *

Approximate Square Footage of Building *

Square Footage of Rental Space (Not Entire Building unless you are using the entire Facility) *

Building Limits *

Contents Limit *

Liability Limits Requested *

Directors and Officers Coverage Requested ($1,000,000 In Coverage) *

Religious Belief / Expressions Coverage Requested ($1,000,000 In Coverage) *

Abuse & Molestation Coverage *

Employment Practice Liability Insurance (Covers Wrongful Termination & Discrimination Law Suits) *

None Owned / Hired Auto Coverage Requested ($1,000,000 In Coverage) *

Crime Coverage *

Business Auto Policy (Church Owned Vehicle) *

VIN Number

Year of Vehicle *

Make of Vehicle *

Model of Vehicle *

Number of Passengers *

Driver Name

First

Last

Drivers License Number

Date of Birth

Umbrella Policy *

Umbrella Limits Requested *

Earthquake Insurance Coverage *

Flood Insurance Coverage *