Notice: This Questionnaire becomes part of the policy and must be signed in ink by the President, Owner or Authorized Representative of the Applicant. Any coverage we issue is due to the reliance of the truth and accuracy of the statements in this Questionnaire. This document must be completed in addition to the ACORD Application.

General Information:

Name of Applicant*

Address*

Web Address*What year did you take over management of this institution?*

Denomination*Size of Congregation*

Loss information for the last three to five years?*

Safety Information:

1. Does the facility have the following?

a. Fire Alarms:YesNo

If yes, are theyLocal AlarmCentral Station

b. Smoke Detectors:YesNo

If yes, are theyHard WiredBattery Operated

c. Burglar Alarms:YesNo

If yes, are theyLocal AlarmCentral Station

d. Emergency Lighting:YesNo

e. Are all exits illuminated?YesNo

2. Are evacuation routes posted throughout the building?YesNo

3. Are there two or more means of egress from the building?YesNo

4. Are all stairs and walkways clear of snow and ice prior to meetings or church services?YesNo

5. Is the building wiring aluminum?YesNo

If yes, are theySingle StrandMulti Strand

6. Is the building wiring composed of:Circuit BreakersFusesKnob & Tube

7. Does the insured have the following:

a. Wood Burning Stove?YesNo

If yes, when was it last cleaned?

b. Wood Burning Fire Place:YesNo

If yes, when was it last cleaned?

General Liability:

1. What is the number of pastors?*

2. Is a nursery available during scheduled church activities?

YesNoIf yes please answer the following:

a. Is the staff voluntary or employees of the church?YesNob. How many days in a week is this service provided?c. What is the average number of children using this service?d. Ages of children in nursery?

Producer's Narrative

Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance 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 subjects that person to criminal and/or civil penalties (In Oregon, the aforementioned actions may constitute a fraudulent insurance act which may be a crime and may subject the person to penalties). (In New York, the civil penalty is not to exceed five thousand dollars ($5,000) and the stated value of the claim for each such violation).
(Other state specific notifications shown below).

Applicable in AL, AR, AZ, DC, LA, MD, NM, RI and WV: Any person who knowingly (or willfully in MD) presents a false or fraudulent claim for payment of a loss or benefit or who knowingly (or willfully in MD) presents false information in an application for insurance is guilty of a crime and may be subject to fines or confinement in prison.

Applicable in Colorado: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the department of regulatory agencies.

Applicable in Florida and Oklahoma: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony (In FL, a person is guilty of a felony of the third degree).

Applicable in Kansas: Any person who, knowingly and with intent to defraud, presents, causes to be presented or prepares with knowledge or belief that it will be presented to or by an insurer, purported insurer, broker or any agent thereof, any written statement as part of, or in support of, an application for the issuance of, or the rating of an insurance policy for personal or commercial insurance, or a claim for payment or other benefit pursuant to an insurance policy for commercial or personal insurance which such person knows to contain materially false information concerning any fact material thereto; or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act.