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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

Required

Last Name

Required

What is your relationship to the Institution?

Required

Street

Required

City

Required

State

Required

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

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.

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 |
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