CHRUCH / MOSQUE QUOTE FORM

First Name: *	Last Name: *
Email Address: *

Name:		Are you set-up as a Non-Profit Corporation LLC
City:		Country:
ST:		Zip Code:

Contact Name:

PH#:

FAX#:

Date Congregation Founded:	HRS of Operation:
FED ID#:	Current INS Comp:
Expiration Date: Open the calendar popup. << < April 2025 > >>   S M T W T F S 14 30 31 1 2 3 4 5 15 6 7 8 9 10 11 12 16 13 14 15 16 17 18 19 17 20 21 22 23 24 25 26 18 27 28 29 30 1 2 3 19 4 5 6 7 8 9 10	Current Premium:$

Claims & Loss History:

PROPERTY SECTION

BUILDING:

CONTENTS:

Sign Coverage Needed:

any Cooking on the premises: Yes No

Build.Conts.Type:	YR Built:	Built SQ FT:
Central Station Alarm : Yes No Sprinkler System: Yes No

LIABILITY SECTION

Liability Limits :

Do employees use their own auto for Church's business? Yes No Days and Hours of Day Care Is there a DAY CARE CENTER on premises? Yes No If yes, is it operated by the Church? Yes No Is Day Care a state or county licensed operation? Yes No Field trips taken by Day Care? Yes No

If yes, describe activities and indicate frequency:

Any church facilities used by outsiders? Yes No	If yes explain:
Playground on Premises? Yes No	If yes, Is it Fenced? Yes No
Would you like the following coverage added to the policy?

Sexual Misconduct: Yes No

Spiritual Counseling: Yes No

Directors and officers Liability: Yes No