Religious Institutions

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 Required
Last Name Required
What is your relationship to the Institution? Required
Street Required
City Required
State Required	AL GA NC SC TN
ZIP / Postal Code Required
Primary Phone Number Required
E-Mail Address Required
Type of Religious Institution? Required
Year Established? Optional
If your Religious Institution has been in existence less than three years, was it an offshoot from another Institution? Optional	Yes No
If YES, name of original institution: Optional
What types of insurance would you like quoted? Optional	Property General Liability Church Directors and Officers LiabilityClergypersons Professional Liability Employee Benefit ProgramsAbuse or Molestation Liability Cemetery LiabilityEmployment Related Practices Liability Business AutoWorkers Compensation
PROPERTY INSURANCE
List out buildings to be insured with building value and contents value Optional
Do you have a parsonage? Optional	Yes No
Please check all items for which you are requesting coverage Optional	Outside Signs Stained Glass Equipment Breakdown Household Personal Property Coverage
Is there cooking on the premises? Required	Yes No
If Yes, please indicate Type: Optional	Range - Commercial Range - Domestic Deep Fat Fryer Gas or Electric Griddle
If YES, What type of protection is used? Optional	Hood Vented Non-Vented Extinguishing System
If you have an Extinguishing System, what type of system? Optional
How often are cooking facilities used on a daily, weekly or monthly basis? Optional
GENERAL LIABILITY INFORMATION (Complete if you are requesting a quote for this coverage)
Any Day Care Facilities? Optional	Yes No
If YES, percentage of day care attendees that are congregation members' children? Optional
List activities other than religious services/education (e.g. pregnancy centers, drug or alcohol counseling programs, clinics, soup kitchens, summer camps, missions, trips, etc.) Optional
Are certificates of insurance obtained from outside organizations using premises? Optional	Yes No
List any Fundraisers anticipated for the upcoming policy period. (Dinners, carnivals, etc) Optional
THE RELIGIOUS INSTITUTION AND AFFILIATES (EXCLUSIVE OF SCHOOL OPERATIONS)
Number of members? Optional
Number of employees? Optional
Number of members on governing board? Optional
Total annual operating budget? Optional
Is there an independent governing board that reviews your books? Optional	Yes No
Do you have controls in place to ensure that donor resources are used in compliance with current tax-exempt requirements? Optional	Yes No
Is an annual financial audit conducted? Optional	Yes No
If YES, by who? Optional
Are you willing to provide copies of audited financial statements upon request? Optional	Yes No
Does the institution have any affiliates? Optional	Yes No
If YES, please provide name, location and description? Optional
Are changes planned for any operations? Optional	Yes No
If YES, please describe: Optional
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? Optional
Number of Administrators? Optional
Number of School Officials? Optional
Number of Teachers (including student teachers, cadet, practice)? Optional
Number of all other employees? Optional
Is there an independent governing board that reviews yours books? Optional	Yes No
Total current budget of school? Optional
Total accumulated deficit or surplus of school? Optional
How many years in the past 5 has there been a deficit (if applicable)? Optional
How many years in the past 5 has there been a surplus (if applicable)? Optional
If there is a deficit, what is being done to eliminate it? Optional
Is an annual financial audit conducted? Optional	Yes No
Are you willing to provide copies of audited financial statements upon request? Optional	Yes No
Most recent student enrollment (include full and part time students)? Optional
Previous 4 years final enrollment count by year? Optional
Has there been any claims in the past 5 years involving any of the following? Optional	BusingTeacher's tenure Teacher's dismissal or demotionOther employment related actions Civil rights actions involving pupilsCivil rights actions involving teachers Other civil rights related actionsAny discliplinary actions involving pupils
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! Optional
Are you aware of any Incidents involving the prior list that have not yet resulted in a claim? Optional	Yes No
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". Optional
Has similar insurance been declined, cancelled or non-renewed? Optional	Yes No
Previous carrier of similar insurance? Optional
CLERGYPERSONS PROFESSIONAL LIABILITY
Effective date of coverage, if other than that of policy? Optional
Number of members of the clergy appointed or employed by the insured? Optional
Have they completed formal educational requirements in theology? Optional	Yes No
If NO, explain: Required
List names and titles of any Lay Ministers/Quasi Clergypersons to be covered in addition to regular clergy: Optional
Do church officials, members or clergy have knowledge of any pending legal actions or proceedings against the church? Optional	Yes No
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? Optional	Yes No
If you answered YES to either question, please explain Optional
EMPLOYEE BENEFIT PROGRAMS LIABILITY (EBL) APPLICATION CLAIMS-MADE BASIS
Average number of employees Optional
Is the Summary Plan Documentation easily understandable and distributed to all employees? Optional	Yes No
If YES, attach copy Optional
If there an Orientation Checklist acknowledging the explanation of benefits and election options chosen signed by the employee? Optional	Yes No
If yes, please attach a copy Optional
Does the insured have a person dedicated to presenting Benefit Plans to employees, such as a Personnel Manager or Employee Benefits Manager? Optional	Yes No
Is there a written plan of continuation of management which promotes conformity of the organization? Optional	Yes No
If YES, please attach a copy Optional
Have any claims been paid in the last 5 years? Optional	Yes No
If YES, please provide date, brief description and amount. Optional
Are you aware of any circumstance which may result in any future claim? Optional	Yes No
If YES, please explain details Required
ABUSE OR MOLESTATION LIABILITY
Has the insured ever had any abuse(including sexual or physical abuse), sexual misconduct or sexual molestation claims? Optional	Yes No
Is there any record or knowledge of any previous incidents which might have resulted in such claims if they had been pursued? Optional	Yes No
Please provide details for any positive response to above Optional
Is there any Insured operated day care/school exposure? Optional	Yes No
If YES, what is the average daily enrollment? Optional
If yes, what is the staff to children ratio? Optional
Is the Insured's facility open to parental visits? Optional	Yes No
Were any premises utilized for day care built or modified for that particular purpose? Optional	Yes No
Does the Insured have a policy addressing abuse, molestation or sexual harassment in all its forms? Optional	Yes No
If the answer is YES, is the policy communicated ANNUALLY to the following employees? Check all that apply! Optional	Staff (employees) Students Volunteers Parents/Community
Are employees and volunteers required to sign an acknowledgement of receipt and understanding of the abuse, molestation and sexual harassment policy? Optional	Yes No
Does the insured have a policy and procedure for screening (fingerprinting, criminal record check, Teacher Credentialing Bureau) all prospective employees? Optional	Yes No
Does the insured have a policy and procedure for screening (finger printing, criminal record check) for all volunteers? Optional	Yes No
If you responded YES to either of the prior questions, please provide details Optional
Are signed dated applications required of all propective employees? Optional	Yes No
Are signed dated applications required of all volunteers? Optional	Yes No
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? Optional	Yes No
Are application references checked and documentation maintained? Optional	Yes No
Has the insured developed and publicized to employees and volunteers abuse, molestation and sexual harassment reporting and investigation procedures? Optional	Yes No
Do you have an adequately trained complaint intake/management coordinator, or a Title IX coordinator? Optional	Yes No
If YES, has the Title IX or equivalent officer/coordinator been appointed by the Insured and adequately trained in these duties? Optional	Yes No
Please provide details of training Optional
Is there any day care/school exposure which is not run by the Insured? Optional	Yes No
If YES, do the operators of such exposure have their own liability insurance, including coverage for abuse or molestation? Optional	Yes No
Is our insured named as an additional insured on the operator's liability policy which includes coverage for abuse or molestation? Optional	Yes No
CEMETERY LIABILITY (If applicable)
Number of bodies interred before effective date? Optional
Estimated number of annual interments Optional
Limits of each claim Optional
Aggregate limits? Optional
PLEASE LET US KNOW
How did you hear about us? Optional	Current Customer Friend - Advertisement - Direct Mail E-Mail Internet Ad Radio Ad Television Ad Yellow Page Listing - Online - Online Blog Internet Search Engine Bing/Live Search Engine Google Search Engine Yahoo! Search Engine - Other - Driving By The Office Business Card Flyer Local Event
Is there anything else that you would like for us to know concerning your quote request? Optional
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. Required
Please provide your TITLE Required
Please provide the DATE that you are signing Required
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.
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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.

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