General Information
Named Insured
Effective Date
Mailing Address
Physical Address,
if different
Phone Number
Contact
Email / Web Address
Federal ID #
Entity
# of Members
Denomination
Primary operation
New
Corp
Renewal
Ind
Partnership
Church Office
Other:
Non-Profit
501 C 3
Headquarters Day Care
Are any staff members/volunteers part of mandatory community services
doing community service in lieu of going to prison?
Any policy or coverage declined/cancelled/non-renewed last 3 years
If yes, reason for cancellation:
Any past losses/claims relating to sexual abuse/molestation allegations,
discrimination or negligent hiring?
Any portion of building/premises rented/leased to others
If yes, describe:
PROPERTY LOCATIONS:
Premises Address
1.
2.
3.
4.
5.
City
State
Zip
PRIOR CARRIER – All lines of business
Company
Term
Line of Business
Y or N
Y or N
Y or N
Y or N
LOSS HISTORY – All Lines of Business (Pending, Open and/or Closed)
Date of Claim
Type of Claim
REQUIREMENTS:
1) Two pictures of each building;
2) Current 3 year loss runs;
3) cost guide estimator for each building;
4) diagram of all buildings.
Amount Paid
Open
Closed
COMMERCIAL PROPERTY
Values
Building
BPP
RC
ACV
Agreed Value
Construction Type
Year of Construction
Occupancy
Protection Class
Feet to Hydrant
Miles to Fire Department
Area: Ground floor/total
Basement sq ft
# of stories
Heating System & year
Electrical System & year

Loc #
Bldg #
Bldg
Bldg
Bldg
Loc #
Bldg #
BPP
BPP
BPP
Bldg
Bldg
Bldg
Loc #
Bldg #
BPP
BPP
BPP
Bldg
Bldg
Bldg
Loc #
Bldg #
BPP
BPP
BPP
Bldg
Bldg
Bldg
inspection date
Type of Roof & year

inspection date
Plumbing – year
Annual Extinguishers
Serviced?
Sprinkler System-Type
Bell Tower, if yes

Y or N
Y or N
Y or N
Y or N
Y or N
Y or N
Y or N
Y or N
Y or N
Y or N
Y or N
Y or N
Y or N
Y or N
Y or N
Y or N
Y or N
Y or N
Y or N
Y or N
Y or N
Y or N
Y or N
Y or N
Y or N
Y or N
Y or N
Y or N
Y or N
Y or N
Y or N
Y or N
Y or N
Y or N
Y or N
Y or N
Y or N
Y or N
Y or N
Supplemental
Cooking/premises, if yes

Y or N
Supplemental
Alarms, if yes
 Supplemental
Bldg locked-not in use
Historical Register
Mortgage/Loss payee

Name & Address
Business Income Limit
Key Person Replacement
Coverage - $25,000
Evacuation Routes
Emergency Lighting
Smoke detectors

Hard-wired/battery
Glass Coverage


Limits
Stained Limit
BPP
BPP
BPP
INLAND MARINE
Coverage
Minister’s BPP
Instruments
Playround Equipment
Sign
Limits
Y or N
Y or N
Y or N
Y or N
GLASS COVERAGE
Coverage
All Glass including Stained Glass
All Glass w/ limited Stained Glass
All Glass w/ $250/pane; $1,000/occurrence all glass
Limits
Y or N
Y or N
Y or N
COMMERCIAL GENERAL LIABILITY
Coverages
General Aggregate
Each Occurrence
Fire Damage
Medical Expenses
Limits
ADDITIONAL COVERAGES
Director’s & Officers
 Supplemental
Employee Benefits
 Supplemental
Professional
 Supplemental
Sexual Misconduct
 Supplemental
Schedule of Hazards:
Classification
Additional Exposures:
TYPE
Animals: riding/owned
Broadcasting: Radio or TV
Climbing Wall
Fireworks
Homeless Shelter
Known Asbestos/Lead Paint
Parking facilities
Pool
 Diving board
 Slide
Publishing
Soup Kitchen
Trampoline/rebounding equipment
Watercraft
Class Code
Premium Basis
Description
Y or N
Y or N
Y or N
Y or N
Y or N
Y or N
Y or N
Y or N
Y or N
Y or N
Y or N
Y or N
Y or N
Y or N
Exposure
DIRECTORS AND OFFICERS
LIMIT: ____________________________
Currently carries D & O coverage
Y or N
Retroactive date; any interruption of coverage
Y or N
Have policies/procedures been reviewed by attorney
Y or N
Are Board of Directors elected by membership
Y or N
Does any one person have authority to make large financial
decisions without approval of governing board
Y or N
Any change in Board of Directors in past year
Y or N
Financial Information:
Annual Revenue
(Prior Year)
Annual Expenses
(Prior Year)
Total Assests
(Prior Year)
Are financial statements prepared & audited annually by an
outside accountant/CPA
If not, how often
If not, by whom
Total Liabilities
(Prior Year)
Y or N
SEXUAL MISCONDUCT
LIMITS: _______________________________
($50/100; $100/300; $250/500; $500/$1M; $1M/3M)
For ALL employees we conduct:
___Nationwide criminal background
___Reference checks(*)
___No criminal background checks
___No reference checks(*)
___Other: _____________________________
____________________________________
____________________________________
For ALL volunteers we conduct:
___Nationwide criminal background
___Reference checks(*)
___No criminal background checks
___No reference checks(*)
___Other: _____________________________
___________________________________
___________________________________
___Statewide criminal and/or sexual
offender background checks
(*) – Reference check includes contacting, at a minimum, 2 organizations in which the applicant has
worked with minors in the past (churches, scouts, etc)
Does your employment/volunteer application include questions about
whether the individual has ever been convicted for any felony, including sexrelated and/or child abuse related offenses
Y or N
Do you require that all volunteers be involved with your organization for 6
months before they are allowed in any position involving contact with minors
Y or N
Do you require that no minor is ever alone with only one adult in any churchsponsored activity except in a counseling situation
Y or N
Have any of your past or present ministers, employees or volunteers ever
been accused, charged convicted, had a claim or been sued in civil court
for any type of sexual misconduct
Y or N
PROFESSIONAL
LIMITS: ________________________________________
TYPE of counsel:
Alcohol
Drugs
Marrigage
Pregnancy
Religious
Other
Licensed
Non-licensed
Fee Based
# of licensed counselors: ____
# of non-licensed counselors: ____
# of fee-based counselors: ____
All counselors licensed as required by law
Y or N
Any counselor’s license suspended, revoked, cancelled
Y or N
Do counselor’s maintain a separate professional liability policy
Y or N
BUSINESS AUTO
Liability Limit
PIP Limit
Uninsured motorist limit
Collision deductible
Comprehensive deductible
Hired/Non-owned
 # of employees
Hired physical damage
Towing
Driver’s Information
Name
Date of Birth
License & State
CDL
Married/Single
Tickets/Accidents
Y or N If yes, how long:
Married
Single
N Y (# and type)
Driver’s Information
Name
Date of Birth
License & State
CDL
Married/Single
Tickets/Accidents
Y or N If yes, how long:
Married
Single
N Y (# and type)
Driver’s Information
Name
Date of Birth
License & State
CDL
Married/Single
Tickets/Accidents
Y or N If yes, how long:
Married
Single
N Y (# and type)
Driver’s Information
Name
Date of Birth
License & State
CDL
Married/Single
Tickets/Accidents
Y or N If yes, how long:
Married
Single
N Y (# and type)
Vehicle Information
Year
Make/Model
VIN
School Bus
 Supplemental
Van
 Supplemental
 Safety Requirements
Cost New
Radius
Full Coverage
Loss Payee:
 If yes, list name & address
Y or N
# of passengers:
Y or N
# of passengers:
Body Type: S or E
Wheelbase: S or E
Electronic Stabilization: Y or N
Dual Rear Wheels: Y or N
Y or N
Y or N
Vehicle Information
Year
Make/Model
VIN
School Bus
Van
Cost New
Radius
Full Coverage
Loss Payee:
 If yes, list name & address
Y or N
# of passengers:
Y or N
# of passengers:
Body Type: S or E
Wheelbase: S or E
Electronic Stabilization: Y or N
Dual Rear Wheels: Y or N
Y or N
Y or N
NOTE:
A vehicle self-inspection report should be completed for each vehicle.
WORKER’S COMPENSATION
LIMITS: _________________________________________
Class Code
1.
2.
3.
4.
5.
6.
Duties/Classes
Payroll
# Employees
full / part-time
Does insured own, operate or lease aircraft or watercraft
Does insured perform their own maintenance on roof/steeple
Does insured operate any camps
Does insured operate any school or day care facilities
Do any volunteers perform regular driving duties on behalf of church
Does insured have cafeterias, soup kitchens or similar cooking
operations at any location
7. Is there any volunteer or donated labor
8. Is there any maintenance/lawn care
9. Sporting activities
Y or N
Y or N
Y or N
Y or N
Y or N
Y or N
Y or N
Y or N
Y or N
If insured has answered Y to any of the above questions, please provide detailed
information below:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
EMPLOYMENT PRACTICES
LIMITS: ____________________________________
RETENTION: _______________________________
# of employees:
____Full Time
____Part-Time
____Temporary
____Seasonal
# of terminations for past 3 years. Include voluntary & involuntary
Year
Voluntary Involuntary
Total
Turnover Ratio
Voluntary
Turnover Ratio
Involuntary
Policies & Practices (check all that apply)
Employment application used during hiring process
Employment application/handbook includes at-will statement
Employment application includes authorization to check references & criminal records
Employment application requires applicant’s signature that all representations are true
Employment application states employer is equal opportunity employer
Applicant distributes employee handbook to each employee
Applicant has written procedures for addressing sexual harassment
Applicant has written procedures for handling employee grievances
Applicant has progressive disciplinary program
Applicant posts all notices required by law
Applicant has adopted a formal Family Medical Leave Act policy
All terminations are reviewed by the HR department or person responsible for this function
Written performance evaluations are provided for all employees
Supervisory employees are trained the proper use of policies & procedures
Employment policies & practices have been reviewed & approved by outside legal counsel
CRIME
CHURCH THEFT:
 Note: deductible $500 unless otherwise indicated
Coverage
Money & Securities only
Blanket EXCLUDING Money & Securities
Blanket INCLUDING Money & Securities
Limit
(IF $25,000 or more, complete Institutional Crime Supplement)
CRIME COVERAGE: Theft, disappearance & destruction
 Note: deductible $500 unless otherwise indicated
Coverage
Limit
Inside
Outside
Other
(IF $25,000 or more, complete Institutional Crime Supplement)
BOND
Coverage
Church Fidelity Bond($10,000 max)
Bond
1. Employee dishonesty blanket
2. Forgery & alteration
Limit
Deductible
None
INSTITUTIONAL CRIME SUPPLEMENT
Is an audit performed?
 If yes, who performs the audit?
Are bank accounts reconciled by someone not authorized to
deposit or withdrawal?
Is countersignature of checks required?
 If yes, who signs check/what is their position?
Will securities be subject to joint control of two or more
responsible employees
Y or N
CPA
Public Accountant
Staff
Other:
Y or N
Y or N
Y or N
N/A
UMBRELLA
Limits: _________________________________
Retention: ___________________
Underlying:
Y or N
Y or N
Y or N
Y or N
Coverages
General Liability
Worker’s Compensation
Business Auto
Director’s & Officers
Limits
CAMPS
Exposure:
_____YMCA/YWCA
_____Horse Camp
______Other
Length of Camping Season:
_____Year Round
_____Seasonal
Opening date: ______________ Closing date: ______________
TOTAL Number of Campers per day: _____________
ATV’s or 3-4 wheeler
Archery
Golf
Hang Gliding
Hayrides
Hot Air Ballooning
Motorbikes
Mountain Climbing
Mud Sports
Parasailing
Surfing
Survival Courses
Sledding
Is there a swimming pool?
 Fenced and locked when not in use
 Diving board
 Pool depth marked
 Certified lifeguard on duty
Y or N
Y or N
Y or N
Y or N
Y or N
Is there beach swimming
 Certified lifeguard on duty
Y or N
Y or N
Are medicines kept in locked cabinets & procedures
for distribution in place?
Y or N
Do you record injuries and action that is taken?
Y or N
Are parents required to sign permission slips authorizing
Emergency medical transport or treatment?
Y or N
Is corporal punishment administered?
Y or N
DAY NURSERY
Liability Limits: ______________________
Medical Limits: _____________________
Square footage of building: _________________
Days & hours of operation: ___________________________________________________
Total Number of children on premises at any given time: __________
Age Group
# of Care Providers
Male
Female
Number of Children
< 18 months
18 to 30 months
30 months to 4 years
Above 4 years
Before school program
After school program
Are appropriate Fire Marshall Inspection Report and evidence of any
required remediation on file
Any staff members/volunteers part of a community services program
i.e. community service in lieu of going to prison
Appropriate licensing requirements met (state & local)
Day care provided in residence
Emergency evacuation procedures in effect
How often are fire drills performed
Do you have written policy outlining the entity’s fire protection
program
Properly functioning UL listed smoke detectors installed in each room
Properly functioning CO detectors installed in each room
Electrical outlets have cover protectors
Medicines are kept in locked cabinets; procedures for distribution in
place
Record of injuries and action taken
Parents sign permission slips authorizing emergency medical transport
or treatment
Written employment practices exist
Corporal punishment administered
Special activities i.e. field trips, etc
Y or N
Y or N
Y or N
Y or N
Y or N
Y or N
Y or N
Y or N
Y or N
Y or N
Y or N
Y or N
Y or N
Y or N
Y or N
KIDNAP / RANSOM
Limits: _________________________________
# of persons to be covered: ____________

(volunteers, mission attendees, students, chaperones, consultants, contractors)
Nature of work/activities – abroad: _________________________________________
___________________________________________________________________________
Total revenue/annual budget of organization: _____________________
Total assets (if applicable) _______________________
Specify the number of individuals to be insured by country. Please provide
breakdown of expatriate/third country nationals and local nationals.
Country
Local Nationals
3rd
Expatriate
country nationals
Specify the country and the approximate number of travel days to be spent within
those countries over the next 12 months.
Country
Approximate duration of stay
Number of Individuals
Do you own, lease or charter any ship or vessel
Do you have a formal Security Department
Do you have a formal Crises Management Plan
Are you interested in preventive security consulting
Have you or any insured person had any claims and/or experienced
threats or incidents that would give rise to a claim within the past 5 years
Have you ever been declined kidnap/ransom insurance
Has any insurer ever cancelled or declined to renew your policy
Y or N
Y or N
Y or N
Y or N
Y or N
Y or N
Y or N
If yes to any of the above, please provide details:
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Miscellaneous Coverages:
1. Bell Tower
2. Builder’s Risk
3. Camps
4. Cyber Liability
5. Day Nursery
6. Individual Risk Premium Modification
7. Kidnap/Ransom
8. School
Fraud Notice
Notice to Applicants: any person who knowingly and with intent to defraud any
insurance company or other person files an application for insurance or statement of
claim containing any materially false information or conceals for the purpose of
misleading, information concerning any fact material thereto, commits a fraudulent
insurance act which is a crime and may subject such person to criminal and civil
penalties.
THE UNDERSIGNED IS AN AUTHORIZED REPRESENTATIVE OF THE APPLICANT AND
REPRESENTS THAT REASONABLE ENQUIRY HAS BEEN MADE TO OBTAIN ANSWERS TO
QUESTIONS ON THIS APPLICATION. HE/SHE REPRESENTS THAT THE ANSWERS ARE TRUE,
CORRECT AND COMPLETE TO THE BEST OF HIS/HER KNOWLEDGE.
_____________________________________
Applicant’s Signature
_____________________________________
Producer’s Signature
_____________________________________
Producer’s Name (please print)
__________________________
Date