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 *

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?

Yes
No

If YES, name of original institution:

What types of insurance would you like quoted?

Property
General Liability
Church Directors and Officers Liability
Clergypersons Professional Liability
Employee Benefit Programs
Abuse or Molestation Liability
Cemetery Liability
Employment Related Practices Liability
Business Auto
Workers Compensation

PROPERTY INSURANCE

List out buildings to be insured with building value and contents value

Do you have a parsonage?

Yes
No

Please check all items for which you are requesting coverage

Outside Signs
Stained Glass
Equipment Breakdown
Household Personal Property Coverage

Is there cooking on the premises? *

Yes
No

If Yes, please indicate Type:

Range - Commercial
Range - Domestic
Deep Fat Fryer
Gas or Electric Griddle

If YES, What type of protection is used?

Hood
Vented
Non-Vented
Extinguishing System

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?

Yes
No

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?

Yes
No

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?

Yes
No

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

Yes
No

Is an annual financial audit conducted?

Yes
No

If YES, by who?

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

Yes
No

Does the institution have any affiliates?

Yes
No

If YES, please provide name, location and description?

Are changes planned for any operations?

Yes
No

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?

Yes
No

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?

Yes
No

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

Yes
No

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?

Busing
Teacher's tenure
Teacher's dismissal or demotion
Other employment related actions
Civil rights actions involving pupils
Civil rights actions involving teachers
Other civil rights related actions
Any 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!

Are you aware of any Incidents involving the prior list that have not yet resulted in a claim?

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".

Has similar insurance been declined, cancelled or non-renewed?

Yes
No

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?

Yes
No

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?

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?

Yes
No

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?

Yes
No

If YES, attach copy

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

Yes
No

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?

Yes
No

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

Yes
No

If YES, please attach a copy

Have any claims been paid in the last 5 years?

Yes
No

If YES, please provide date, brief description and amount.

Are you aware of any circumstance which may result in any future claim?

Yes
No

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?

Yes
No

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

Yes
No

Please provide details for any positive response to above

Is there any Insured operated day care/school exposure?

Yes
No

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?

Yes
No

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

Yes
No

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

Yes
No

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

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?

Yes
No

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

Yes
No

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

Yes
No

If you responded YES to either of the prior questions, please provide details

Are signed dated applications required of all propective employees?

Yes
No

Are signed dated applications required of all volunteers?

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?

Yes
No

Are application references checked and documentation maintained?

Yes
No

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

Yes
No

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

Yes
No

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

Yes
No

Please provide details of training

Is there any day care/school exposure which is not run by the Insured?

Yes
No

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

Yes
No

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

Yes
No

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.

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Life & Disability

Restaurant & Liquor

Garage & Dealership

Business & All Other

Umbrella

Religious Institutions

Contact Us Today! 770-974-0670

Resources

Contact Us

Auto
&
Home

Life
& Disability

Contact Us Today!
770-974-0670