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Michael W. Smith Agency

Revised:

May 06, 2015

Church / Synagogue

 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.

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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?
 
 

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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

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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

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Additional Comments


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Number of hits since August 15, 1998

 

 

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