Church Insurance Quote Form
1. Name Business:
Name Owner:
E-Mail Address:
2. Address / Zip:
3. Bus. Phone / Fax / Home:
Company Name (not agent):
Policy Number:
Expiration Date:
6. Please indicate if Church has any of the coverage in place or interested in obtaining more info:
Parsonage Residence
Pastoral Liability
Day Care Operations
Sexual Molestation
Directors & Officers Liability
Commercial Auto
7. Building Location #:
Description of Property:
8. Exterior Walls:
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Brick with Interior Wood Wall Studs
Metal Only
Brick with Interior Concrete
Brick with Interior Metal Wall Studs
Concrete Block Only
Siding with Interior Wood Wall Studs
Other
Roof:
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Shingle with Interior Wood Frame
Shingle with Interior metal
Frame Deck
Metal Only
Sprinkled:
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Yes
No
Year Built:
Number of floors:
Basement:
Ground Floor Area (LxW):
Second Floor Area (LxW):
Basement Floor Area (LxW):
Total Square Ft:
9. Coverage: Property
Church Building $
Property $
LIABILITY:
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Please Select One
$10,000
$20,000
Other
Deductible
10. Central Heat?:
Heating & Cooling:
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Gas
Electric
Steam Boiler
Other
11. Name of Fire Dept.:
12. Miles from Fire Dept.:
13. In City limits?:
Distance from nearest Fire Hydrant (ft):
Fire/Burglar Alarm Devices:
12. Claims History last 5 years-Date of Loss:
13. Amount Paid & Description of occurance:
