House of Worship Insurance: Step 1 of 4 25% Name of Insured:(Required) First Last Date of Birth:(Required) MM slash DD slash YYYY Phone Number:(Required)Email Address:(Required) Mailing Address:(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country House of Worship Address:(Required) Same as Mailing Address: Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Name of Religious Organization:(Required) Replacement Value of House of Worship:(Required)Applicant's Role at the Religious Organization(Required)Select OnePastorAdministrativeBoard MemberFinancialStewardshipOtherNumber of Members of House of Worship:(Required)Does your Religious Organization have a Website?:(Required)Select OneYesNoWebsite URL:(Required) Is your House of Worship Currently Insured?:(Required)Select OneYesNoCurrent Provider(Required) Expiration Date:(Required) MM slash DD slash YYYY Yearly Premium:(Required)Has there been any Claims Within the Past 3 Years(Required)Select OneYesNoClaims:(Required)Details of Claim:Date of Claim:Value of Claim: Add RemoveFEIN Number:(Required) Religious Organization Denomination:(Required) Do you do Background Checks on Employees or Volunteers:(Required)Select OneYesNoAny Updates within the last 20 years to the Building?:(Required)Select OneYesNoType of Roof Material:(Required)Select OneShingleClay TileConcrete TilePoured ConcreteMetalRolled RoofingWood ShinglesTPOType of Plumbing Material:(Required)Select OneCopperCast IronGalvanized SteelPEXCPVC PipePolybutyleneOtherHas the Roof been Replaced?:(Required)Select OneYesNoHas the Plumbing been Replaced?:(Required)Select OneYesNoYear of last roof Replacement:(Required) Year of last Plumbing Replacement:(Required) Electric Panel Type:(Required)Select OneCircuit BreakerFusesKnob and TubeAre there any Playgrounds on Campus?:(Required)Select OneYesNoNumber of Playgrounds on Campus:(Required)Does your Religious Organization Provide any of the Below Services?: None of These Food Pantry Clothing Donation Medical Services Meal Provisioning Biblical Counsel Addiction Ministry Licensed Counsel Bible School Preschool K-12 Other Specify Other:(Required) Does the House of Worship own a Parsonage?:(Required)Select OneYesNoHow many?:(Required)Parsonage Address(Required) Parsonage is on the Property of the House of Worship Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Drivers:Does the Religious Organization have any Assigned/Regular Drivers?:(Required)Select OneYesNoNumber of Regular/Assigned Drivers:(Required)Select One1234567Driver 1:Name:(Required) First Last Date of Birth:(Required) MM slash DD slash YYYY Gender:(Required)Select OneMaleFemaleAny Claims or Violations in the last 3 years?:(Required)Select OneYesNoClaims or Violations:(Required)Details of Incident:Date of Incident:Value of Incident: Add RemoveDriver 2:Name:(Required) First Last Date of Birth:(Required) MM slash DD slash YYYY Gender:(Required)Select OneMaleFemaleAny Claims or Violations in the last 3 years?:(Required)Select OneYesNoClaims or Violations:(Required)Details of Incident:Date of Incident:Value of Incident: Add RemoveDriver 3:Name:(Required) First Last Date of Birth:(Required) MM slash DD slash YYYY Gender:(Required)Select OneMaleFemaleAny Claims or Violations in the last 3 years?:(Required)Select OneYesNoClaims or Violations:(Required)Details of Incident:Date of Incident:Value of Incident: Add RemoveDriver 4:Name:(Required) First Last Date of Birth:(Required) MM slash DD slash YYYY Gender:(Required)Select OneMaleFemaleAny Claims or Violations in the last 3 years?:(Required)Select OneYesNoClaims or Violations:(Required)Details of Incident:Date of Incident:Value of Incident: Add RemoveDriver 5:Name:(Required) First Last Date of Birth:(Required) MM slash DD slash YYYY Gender:(Required)Select OneMaleFemaleAny Claims or Violations in the last 3 years?:(Required)Select OneYesNoClaims or Violations:(Required)Details of Incident:Date of Incident:Value of Incident: Add RemoveDriver 6:Name:(Required) First Last Date of Birth:(Required) MM slash DD slash YYYY Gender:(Required)Select OneMaleFemaleAny Claims or Violations in the last 3 years?:(Required)Select OneYesNoClaims or Violations:(Required)Details of Incident:Date of Incident:Value of Incident: Add RemoveDriver 7:Name:(Required) First Last Date of Birth:(Required) MM slash DD slash YYYY Gender:(Required)Select OneMaleFemaleAny Claims or Violations in the last 3 years?:(Required)Select OneYesNoClaims or Violations:(Required)Details of Incident:Date of Incident:Value of Incident: Add RemoveVehicles:Does the Religious Organization own any Vehicles? (e.g. Vans, Busses):(Required)Select OneYesNoHow many Vehicles?:(Required)Select One1234567Vehicle 1:Year:(Required) Make:(Required) Model:(Required) VIN:(Required) Vehicle 2:Year:(Required) Make:(Required) Model:(Required) VIN:(Required) Vehicle 3:Year:(Required) Make:(Required) Model:(Required) VIN:(Required) Vehicle 4:Year:(Required) Make:(Required) Model:(Required) VIN:(Required) Vehicle 5:Year:(Required) Make:(Required) Model:(Required) VIN:(Required) Vehicle 6:Year:(Required) Make:(Required) Model:(Required) VIN:(Required) Vehicle 7:Year:(Required) Make:(Required) Model:(Required) VIN:(Required) Please Upload any Declaration Pages, Inspection Results, and any Other Important Documents here:File(s) Drop files here or Select files Max. file size: 98 MB. Anti-Spam Check:CAPTCHA
