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Home > Church > Religious Institutions
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Religious Institutions


 D. Ward Insurance Services, Inc since 1988
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RELIGIOUS INTUTION QUOTE FORM
The Quote Form is our preliminary process of obtaining the necessary underwriting information. Be as thorough as possible. The current policy and claim history will also be required as part of the underwriting process.
First Name *
Last Name *
What is your relationship to the Institution? *
Street *
City *
State *
ZIP / Postal Code *
Primary Phone Number *
E-Mail Address *
Type of Religious Institution? *
Year Established?
If your Religious Institution has been in existence less than three years, was it an offshoot from another Institution?

If YES, name of original institution:
What types of insurance would you like quoted?









PROPERTY INSURANCE
List out buildings to be insured with building value and contents value
Do you have a parsonage?

Please check all items for which you are requesting coverage



Is there cooking on the premises? *

If Yes, please indicate Type:



If YES, What type of protection is used?



If you have an Extinguishing System, what type of system?
How often are cooking facilities used on a daily, weekly or monthly basis?
GENERAL LIABILITY INFORMATION (Complete if you are requesting a quote for this coverage)
Any Day Care Facilities?

If YES, percentage of day care attendees that are congregation members' children?
List activities other than religious services/education (e.g. pregnancy centers, drug or alcohol counseling programs, clinics, soup kitchens, summer camps, missions, trips, etc.)
Are certificates of insurance obtained from outside organizations using premises?

List any Fundraisers anticipated for the upcoming policy period. (Dinners, carnivals, etc)
THE RELIGIOUS INSTITUTION AND AFFILIATES (EXCLUSIVE OF SCHOOL OPERATIONS)
Number of members?
Number of employees?
Number of members on governing board?
Total annual operating budget?
Is there an independent governing board that reviews your books?

Do you have controls in place to ensure that donor resources are used in compliance with current tax-exempt requirements?

Is an annual financial audit conducted?

If YES, by who?
Are you willing to provide copies of audited financial statements upon request?

Does the institution have any affiliates?

If YES, please provide name, location and description?
Are changes planned for any operations?

If YES, please describe:
SEPARATE SCHOOL OPERATIONS OF THE INSURED (if applicable)
The following are insureds under this insurance: The educational affiliate, its board, committee, board of trustees, members of the board or committee, trustees, directors and all employees including student teachers and volunteers
Number of members comprising the governing board?
Number of Administrators?
Number of School Officials?
Number of Teachers (including student teachers, cadet, practice)?
Number of all other employees?
Is there an independent governing board that reviews yours books?

Total current budget of school?
Total accumulated deficit or surplus of school?
How many years in the past 5 has there been a deficit (if applicable)?
How many years in the past 5 has there been a surplus (if applicable)?
If there is a deficit, what is being done to eliminate it?
Is an annual financial audit conducted?

Are you willing to provide copies of audited financial statements upon request?

Most recent student enrollment (include full and part time students)?
Previous 4 years final enrollment count by year?
Has there been any claims in the past 5 years involving any of the following?







If you checked any prior field, please attach a sheet of paper describing the incident including date, amounts of all judgments, reserves and demands. Please note See Attached here!
Are you aware of any Incidents involving the prior list that have not yet resulted in a claim?

If yes, please describe on an attached sheet of paper including the date, all known information including demands made either verbally or in writing. Please write "See Attached".
Has similar insurance been declined, cancelled or non-renewed?

Previous carrier of similar insurance?
CLERGYPERSONS PROFESSIONAL LIABILITY
Effective date of coverage, if other than that of policy?
Number of members of the clergy appointed or employed by the insured?
Have they completed formal educational requirements in theology?

If NO, explain: *
List names and titles of any Lay Ministers/Quasi Clergypersons to be covered in addition to regular clergy:
Do church officials, members or clergy have knowledge of any pending legal actions or proceedings against the church?

Are church officials, members or clergy aware of any incident that may result in a future claim against the church that might fall in the scope of this insurance?

If you answered YES to either question, please explain
EMPLOYEE BENEFIT PROGRAMS LIABILITY (EBL) APPLICATION CLAIMS-MADE BASIS
Average number of employees
Is the Summary Plan Documentation easily understandable and distributed to all employees?

If YES, attach copy
If there an Orientation Checklist acknowledging the explanation of benefits and election options chosen signed by the employee?

If yes, please attach a copy
Does the insured have a person dedicated to presenting Benefit Plans to employees, such as a Personnel Manager or Employee Benefits Manager?

Is there a written plan of continuation of management which promotes conformity of the organization?

If YES, please attach a copy
Have any claims been paid in the last 5 years?

If YES, please provide date, brief description and amount.
Are you aware of any circumstance which may result in any future claim?

If YES, please explain details *
ABUSE OR MOLESTATION LIABILITY
Has the insured ever had any abuse(including sexual or physical abuse), sexual misconduct or sexual molestation claims?

Is there any record or knowledge of any previous incidents which might have resulted in such claims if they had been pursued?

Please provide details for any positive response to above
Is there any Insured operated day care/school exposure?

If YES, what is the average daily enrollment?
If yes, what is the staff to children ratio?
Is the Insured's facility open to parental visits?

Were any premises utilized for day care built or modified for that particular purpose?

Does the Insured have a policy addressing abuse, molestation or sexual harassment in all its forms?

If the answer is YES, is the policy communicated ANNUALLY to the following employees? Check all that apply!



Are employees and volunteers required to sign an acknowledgement of receipt and understanding of the abuse, molestation and sexual harassment policy?

Does the insured have a policy and procedure for screening (fingerprinting, criminal record check, Teacher Credentialing Bureau) all prospective employees?

Does the insured have a policy and procedure for screening (finger printing, criminal record check) for all volunteers?

If you responded YES to either of the prior questions, please provide details
Are signed dated applications required of all propective employees?

Are signed dated applications required of all volunteers?

If you answered Yes, to either of two prior questions, does the application ask whether an investigation had been conducted or was pending at the time of separation from prior employment or volunteeer work?

Are application references checked and documentation maintained?

Has the insured developed and publicized to employees and volunteers abuse, molestation and sexual harassment reporting and investigation procedures?

Do you have an adequately trained complaint intake/management coordinator, or a Title IX coordinator?

If YES, has the Title IX or equivalent officer/coordinator been appointed by the Insured and adequately trained in these duties?

Please provide details of training
Is there any day care/school exposure which is not run by the Insured?

If YES, do the operators of such exposure have their own liability insurance, including coverage for abuse or molestation?

Is our insured named as an additional insured on the operator's liability policy which includes coverage for abuse or molestation?

CEMETERY LIABILITY (If applicable)
Number of bodies interred before effective date?
Estimated number of annual interments
Limits of each claim
Aggregate limits?
PLEASE LET US KNOW
How did you hear about us?
Is there anything else that you would like for us to know concerning your up and coming Renewal?
SIGNATURE REQUIRED
I have provided all of the above information for insurance purposes and I state all information is true to the best of my knowledge. I also understand that I am to discuss with the agent at D. Ward Insurance my desired limits and coverage.
By typing my name warrants my signature. *
Please provide your TITLE *
Please provide the DATE that you are signing *
ADDITIONAL INFORMATION NEEDED
Please note - A copy of the policy and claim history will be required. They can be obtained from your current agent by requesting the documents to be sent electronically to you.
ENTER VALIDATION CODE
For Security of your personal information, enter code and press submit
Submission Validation
Required

Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages.  Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company.  If you have any questions, please feel free to contact us.

Per the terms of our online privacy policy we will not resell your information to any third-party.

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Physical: 3440 Blue Springs Road, #503j, Kennesaw, GA 30144

P: (770) 974-0670 | F: (770) 974-8577 |
E: dward@dwardins.com

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