Storefront/Community Church APP

Storefront:Community Church APP PDF Download

Storefront/Community Churches APP

  • Storefront/Community Church Application – All States

    You can obtain a quote by providing the information in Section i - instant quote below, Subject to the remainder provided prior to binding

  • I. INSTANT QUOTE INFORMATION

    Instant Quote is only available for accounts with no losses in the past 3 years. If there is loss history, please complete the entire application.
  • (if different)
  • Property Section (complete for each building)

  • Protection class:

    (If No, skip a-c)
  • sq ft.
  • General Liability Section

    (not to exceed the GL limit)
  • (please complete our Child Care Operations Supplemental Application)
    (If No, skip a-f)
  • Additional Interests (AI = Additional Insured, LP=Loss Payee, M=Mortgagee)

  • NameRelationship/InterestAddressCity, State, ZipAI, LP, M 
    Add a new row
    Please use the + button to the right to add additional Interests.
  • Non Profit Directors & Officers/Employment Practices Liability Section

  • (If >$2 million attach the most recent 12-month financial statement)
  • this year :next year:3rd year: 
  • Full-time employees:Part-time:Temporary/Seasonal:Volunteers: 
    Add a new row
  • II. LOSS INFORMATION FOR THE PAST THREE YEARS

  • YearStatusIncurred ($)Description 
    Add a new row
  • YearStatusIncurred ($)Description 
    Add a new row
  • GENERAL LIABILITY

  • (please complete our Social Services - Residential Facilities Application)
  • ABUSE AND MOLESTATION LIABILITY

  • PASTORAL PROFESSIONAL LIABILITY

  • HIRED AND NON-OWNED AUTO

    Note: If Hired/Non-owned is checked, limit will equal general liability occurrence limit.
  • PROPERTY

    (If “Yes,” answer a-c)
  • Complete the following questions only if special cause of loss is requested for the building:

  • NON PROFIT DIRECTORS AND OFFICERS AND EMPLOYMENT PRACTICES LIABILITY

    If “Yes,” please complete the Non Profit Subsidiary Addendum (NPSADD).
  • InsurerLimits of LiabilityPremiumRetentionPolicy Period 
    (If “Yes,” please forward a completed USLI supplemental claims application.)
    (If “Yes,” please forward a completed USLI supplemental claims application.)
  • Virginia Notice: Statements in the application shall be deemed the insured’s representations. A statement made in the application or in any affidavit made before or after a loss under the policy will not be deemed material or invalidate coverage unless it is clearly proven that such statement was material to the risk when assumed and was untrue.

    Minnesota Notice: Authorization or agreement to bind the insurance may be withdrawn or modified only based on changes to the information contained in this application prior to the effective date of the insurance applied for that may render inaccurate, untrue or incomplete any statement made with a minimum of 10 days notice given to the insured prior to the effective date of cancellation when the contract has been in effect for less than 90 days or is being canceled for nonpayment of premium.

    Colorado Fraud Statement: 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.

    District of Columbia Fraud Statement: WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant.

    Florida Fraud Statement: 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 of the third degree.

    Kentucky Fraud Statement: 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.

    Maine and Washington Fraud Statement: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits.

    New Jersey Fraud Statement: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties.

    New York Fraud Statement: 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 shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.

    Ohio Fraud Statement: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.

    Oklahoma Fraud Statement: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.

    Pennsylvania Fraud Statement: 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 subjects such person to criminal and civil penalties.

    Tennessee and Virginia Fraud Statement: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.

    Fraud Statement (All Other States): Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

    If your state requires that we have information regarding your Authorized Retail Agent or Broker, please provide below.