Structure Information
Type	Construction	Roof	Foundation	Age Of Church
1 Story 1 1/2 Story 2 Story Split Level Bi-Level Other	Frame Stucco Veneer Masonry Other	Asphalt Shingle Wood Shingle Tile or Slate Other	Basement Crawl Space Slab Other	yrs.
		Age of roof: yrs.

 

Features
Bathrooms	Basement	Deck/Porch/Patio
# of Full: # of Half:	None Finished Unfinished Sq. Ft.:	Deck Sq. Ft.:     Porch Sq. Ft.:

 

Additional Features
Heating System	Central Air	Fire Sprinkler System	Security Alarm	Fire Alarm	Smoke Detector
None Electric Gas Oil Propane Solar Other	Yes	Yes	None Monitored Not Monitored	None Monitored Not Monitored	Yes

 

Property Questions If the Church building is over 25 years old, please answer the following:
Year Electricity was updated: Is it on circuit breakers?:		Yes   No
Year Plumbing was updated: Copper or Galvanized plumbing?:		Copper   Galvanized   Other:
Year Building was last re-roofed:

 

Secondary Property Questions ( Fill out if there is a secondary building on the property ) (If there is more than one secondary building to be insured on the property, please use the Additional Comments section at the bottom of this form to provide more information )
Age of building /Year Built:	Type of building construction:	Number of stories:	Square feet:	How is this building used?
	--Select One-- FrameStuccoMasonry/Brick Fire ResistiveOther		sq. ft.
If the building is over 25 years old, please answer the following:
Year Electricity was updated: Is it on circuit breakers?:		Yes   No
Year Plumbing was updated: Copper or Galvanized plumbing?:		Copper   Galvanized   Other:
Year Building was last re-roofed:

 

Secondary Building -- Additional Features
Heating System	Central Air	Fire Sprinkler System	Security Alarm	Fire Alarm	Smoke Detector
None Electric Gas Oil Propane Solar Other	Yes	Yes	None Monitored Not Monitored	None Monitored Not Monitored	Yes

 

Liability Questions
Please provide information on previous insurance carrier:
Previous Ins. Carrier:	Policy number:	Prior premium:	Policy renewal date:
		$
Please provide information about your Church:
# Buildings:	# Playgrounds / Sports Fields:		Projected annual Church payroll:
			$

 

Coverage Limits
Building:	Contents (equipment, inventory, supplies, etc.):		Aggregate Limit:
$	$		--Select One-- $300,000/1,000,000$500,000/$1,500,000$1,000,000/3,000,000
Musical Instruments:	Glass or signs:	Occurrence Limit:	Medical Expense Limit:
$	$	--Select One-- $300,000/$600,000$500,000/$1,000,000 $1,000,000/$2,000,000	--Select One-- $1,000$2,000$5,000 $10,000Other
If Glass Coverage is needed, please provide dimensions:
Please list other coverages you may need:

 

Miscellaneous Information
Name of Additional Insured (Landlord):
Mailing Address:
City:	State:   Zip:

 

Additional Comments

Please give any additional comments you feel appropriate for this quotation. If you have additional information where there was not enough fields above, please enter them here.

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