Minnesota MN Church / Synagogue insurance quote property liability clergy professional

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Michael W. Smith Agency

Revised:

May 06, 2015

763-535-7293

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	Information
	Please provide information on the type of business your company does. Let me know about special concerns you have.

This is a request for a Minnesota Church / Synagogue insurance quote, not a policy application. Submitting this form does not obligate you to purchase any insurance products. Please complete this form as accurately as possible. Church / Synagogue insurance rates are subject to change.

Contact Information

Contact Name
Church / Synagogue Name
Street
City, State ZIP
E-mail
Phone
Cell Phone
Fax
Web Address

Church / Synagogue Information

Year Church Was Founded
Current Number of Members
Number of Members Last Year
Number of Pastors / Priests / Rabbis
Number of Employees
Number of Board Members
What is the extent of counseling services provided by Clergy?

Insurance Information

Effective Date Needed
Years of Loss Runs Available

Insurance Carrier Information
(if you have no previous insurance, enter "none" for the Year)

Year	Carrier	Policy Number	Limits	Premium

Loss History

Check here if no losses in the past 5 years

none

Please describe any losses you've had in the past five years.

Date of Loss	Type of Loss	Description of Loss	Amount Paid	Reserve

Coverage's Requesting Quote On

Property	General Liability
Business Auto	Umbrella
Clergy Professional	Equipment Breakdown
Sexual Molestation	Electronic Data Processing
Employee Dishonesty / Crime	Glass & Sign
Workers Compensation	Boiler & Machinery
Accounts Receivable/Valuable Papers	Missionary Travel Health Insurance
Hired / Non-Owned Auto	Bond
Kidnap & Ransom	Employment Practices

Underwriting Questions

General Information I

Explain all "Yes" responses	Yes	No	Explain all "Yes" responses	Yes	No
Are you a subsidiary of another entity or do you have any subsidiaries?			Have you been active in or are you currently active in joint ventures?
During the past five years, has any company ever cancelled, declined or refused to issue any similar insurance to you?			Any bankruptcies or credit liens against you in the past five years?
Explain all yes responses

General Information II

	Yes	No	Explain all "Yes" responses
Is the Church / Synagogue building on the Historical Register?
Was the building originally NOT built as a church?
Is there a steeple?
If there is a steeple, is there grounded lightning protection?
Is the lightning protection UL Approved?
Does the Church / Synagogue operate or house a day care, preschool or full-time school?
Does the Church / Synagogue sponsor overnight trips which include children under the age of 16?
Does the Church / Synagogue sponsor any foreign trips?
Has the Church / Synagogue or any of its past or present directors, officers, trustees, committee members, employees or anyone acting in a ministerial capacity ever been involved in a lawsuit or claim for sexual abuse, misconduct, or molestation, or has any charge or arrest been made against said person for the same?
Are you aware of any past or present incidents that could result in a claim of this nature?

General Information III

List all groups and auxiliary organizations operating within the sponsorship or sanction of the Church / Synagogue:
List outside groups that are allowed to use the Church / Synagogue premises:
	Yes	No	If No, Explain
If outside groups are allowed to use the premises, are certificates of insurance obtained?
	Yes	No	If yes, Explain the area and to whom is spaced leased
Does the Church / Synagogue formally lease any space to others?

General Information IV
Complete this section if Church / Synagogue has cooking facilities

	Yes	No
Deep Fat Fryer?
If there is a deep fat fryer, is there a UL-300 Ansul extinguishing system?
Grill?
Does the fire suppression system/duct work have a semi-annual inspection by a service contractor?
How many times per week is cooking done?

Premises Information

Location #1

Address		City	State	Zip Code

Year Built	Interest	Type of Building	Construction of Building

Responding Fire Department		Miles to Fire Department	Feet to Fire Hydrant

Location #2

Address		City	State	Zip Code

Year Built	Interest	Type of Building	Construction of Building

Responding Fire Department		Miles to Fire Department	Feet to Fire Hydrant

Location #3

Address		City	State	Zip Code

Year Built	Interest	Type of Building	Construction of Building

Responding Fire Department		Miles to Fire Department	Feet to Fire Hydrant

Additional Comments

Number of hits since August 15, 1998


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