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Church Property & Casualty Insurance ApplicationPlease return completed application to:Wilma Miller Insurance – Morrow Insurance Group18936 N. Dale Mabry HighwayTampa, FL 33548FAX: (813) 830-7870 E-Mail: Wilma@integrityfirst.ccChurch NameChurch File NumberMailing Address City State ZipPhone Number () FAX () E-MailPrimary contact person’s name at churchName of person completing this form Date1.2.3.4.5.6.7.Average Weekly Attendance Capacity of SanctuaryAre premises used by outside groups? If yes, describeDescribe Youth ActivitiesDescribe Fund Raising ActivitiesIs there a playground on premises? Yes No Is there a boundary restraint (fence) ? Yes NoType of ground cover below play equipmentIs there a playground equipment maintenance program? Yes NoSPECIAL ACTIVITIES/SERVICESDo you own or sponsor any of the following:School Yes No - If yes, a special application is required for schools – contact Wilma MillerCemetary Yes NoOrphanage Yes NoSoup Kitchen Yes NoVacant or unoccupied buildings Yes NoSwimming Pool Yes NoSEXUAL MISCONDUCT1. Does your church have a written sexual misconduct policy in place? Yes No If yes, pleasedescribe:2. Are volunteers and compensated workers for any position involving supervision or custody of children underage 18 screened? Yes No3. Are completed job applications for all paid workers kept on file? Yes No(Page 1 of 6)Completed form to be returned to Wilma Miller – 18936 N. Dale Mabry Hwy., Tampa, FL 33548 – Phone Number (813) 3650987 or 800-741-1955 - Fax 813/830-7870 or e-mail to wilma@integrityfirst.cc.
Church Property & Casualty Insurance Application4. Are all volunteers or workers involved in the supervision of children under age 18 required to attend thechurch for a minimum of at least six months? Yes No5. Do you have the two-adult policy rule regarding supervision of children under 18? Yes No6. Is a staff member ever alone with a child behind closed doors, away from other staff members? Yes No7. Do you have any past or pending claims relating to any form of sexual misconduct? Yes NoPASTORAL LIABILITY1.2.3.4.5.6.Is the clergy licensed and/or ordained? Yes NoDoes the clergy perform counseling functions, other than biblical counseling? Yes NoHas the clergy received formal training in counseling? Yes NoDoes the applicant advertise counseling to non-congregation members? Yes NoIs a fee required for counseling? Yes NoIf other than biblical counseling is offered, do you have a separate professional liability policy? If yes, pleasegive carrier name: Policy number7. Are there any past or pending claims against your professional liability coverage? Yes NoCHILD CARE FACILITIES1. Do you operate any of the following:a. Before / after school program? Yes Nob. Day Care? Yes Noc. Kindergarten? Yes NoIf answer to a-c is yes, please complete the attached CHILD CARE QUESTIONNAIRE.2. Do you have a daycare as a tenant? Yes NoDIRECTORS AND OFFICERS LIABILITY COVERAGE - This is an optional coverage. Request application ASB-6007 andsubmit if coverage is desired.COMMERCIAL AUTOMOBILE COVERAGEPlease verify any autos, vans or buses owned by the church you desire to be quoted for coverage. If vehicle(s) haveprior coverage, give name of carrier and effective date. Prior Carrier: CoverageEffective Date: Also, please answer questions below:Do you provide transportation services?Yes NoIf yes, do you obtain MVR’s (Motor Vehicle Reports) on all drivers?Yes NoIs training provided for all new drivers? Yes NoHow often are your church vehicles used? Daily Weekly Monthly OtherEstimated yearly mileage?(Page 2 of 6)Completed form to be returned to Wilma Miller – 18936 N. Dale Mabry Hwy., Tampa, FL 33548 – Phone Number (813) 3650987 or 800-741-1955 - Fax 813/830-7870 or e-mail to wilma@integrityfirst.cc.
Church Property & Casualty Insurance ApplicationINCREASED MONEY & SECURITIES COVERAGECoverage for money and securities will automatically double for the period beginning four days preceding Easter,Thanksgiving, Christmas and one day of choice, and ending four days after these special days. Indicate the day of yourchoice:PROFESSIONAL LIABILITY AND WORKERS’ COMPENSATIONPOSITIONNUMBER OFFULL-TIMENUMBER OFPART TIMEANNUAL PAYROLLINCLUDING ALMAINTENANCEOTHER (EXPLAIN)MORTGAGE INFORMATION: Please list the name of the Mortgage Holder (s) for your building(s):Building Address/Description:Name of Lender: Address:City: State: Zip: Loan Number:Fax Number: ()Does your church have separate Flood Policy(s)? Yes NoIf yes, please provide a copy of the policy.RENTAL INFORMATION: Rental Information applies only to churches renting/leasing space from another party.Address of building being rented City State ZipTotal of square footage being rented Value of Contents left on-sitePlease provide name and address of landlord if they require certificate of liability insurance(Page 3 of 6)Completed form to be returned to Wilma Miller – 18936 N. Dale Mabry Hwy., Tampa, FL 33548 – Phone Number (813) 3650987 or 800-741-1955 - Fax 813/830-7870 or e-mail to wilma@integrityfirst.cc.
Church Property & Casualty Insurance ApplicationChurch Operated Daycare Facility Supplemental Questionnaire for Day Cares, KindergartenIf tenant operated (someone besides the local church), what is the square footage of the day care?IF CHURCH OPERATED:1.2.3.4.5.6.7.Hours of operation? am/pm to am/pmAre records kept on all injuries? Yes NoIs a physical exam or medical certificate required for each child? Yes NoIs there a written drop-off and pickup procedure? Yes NoAre parents free to visit facility at any time? Yes NoIs corporal punishment practiced? Yes No (if yes, attach written procedure)Specify the applicable number for each age group:# Children# AdultsInfantsToddlers3-45-6Kindergarten8. Are staff members trained in first aid, including CPR? Yes No9. Do you care for children who are physically or emotionally impaired? Yes No10. Are field trips conducted? Yes No If yes, describe the nature of trips and mode of transportation:11. On what floor level is the daycare located12. Is there a written evacuation procedure? Yes No13. Are there regular fire drills? Yes NoDAY CARE LICENSE1. Is the day care currently licensed? Yes No2. Has the license ever been revoked? Yes NoEMPLOYEES1. Describe the educational background of the Director:2. Do hiring practices include:a. Completed application? Yes Nob. Pre-employment physical? Yes Noc. Contacting personal reference? Yes Nod. Tuberculosis test? Yes Noe. Police background check? Yes No3. Do employees dispense medicine? Yes NoIf yes, are prescription labels or instructions from medical personnel required? Yes No(Page 4 of 6)Completed form to be returned to Wilma Miller – 18936 N. Dale Mabry Hwy., Tampa, FL 33548 – Phone Number (813) 3650987 or 800-741-1955 - Fax 813/830-7870 or e-mail to wilma@integrityfirst.cc.
Church Property & Casualty Insurance ApplicationPROPERTY AND AUTO SCHEDULEChurch Name File NumberCity County Zip CodeComments on Building Maintenance (i.e. roof, plumbing, electrical)BuildingAddressSquareFootageOccupancy rYear Built andConstructionTypeCHURCH OWNED AUTOSYearMakeModelTypeVINCurrent Value# ofSeatsAPPROVED DRIVERS (MUST HAVE CURRENT 3 YEAR MVR ON FILE AT CHURCH)FIRST NAMELAST NAMELICENSE #CDL –YES/NOBIRTH DATELICENSE STATEMinimum Driver Age – 21. Driver must be at least 25 to drive passenger van.(Page 5 of 6)Completed form to be returned to Wilma Miller – 18936 N. Dale Mabry Hwy., Tampa, FL 33548 – Phone Number (813) 3650987 or 800-741-1955 - Fax 813/830-7870 or e-mail to wilma@integrityfirst.cc.
Church Property & Casualty Insurance ApplicationPLEASE KEEP A COPY OF THE COMPLETED APPLICATION FOR YOUR FILE!!!PRIOR INSURANCE COVERAGEPlease provide a copy of your current Insurance Policy Declarations Page and answer the following questions:Name of Present Insurance Carrier & Policy Number(s)Policy Expiration Date(s)COVERAGES (checkYes or No for each coverage you’ve had):Property :Yes NoWind :Yes NoLiability:Yes NoWork Comp:Yes NoAuto:Yes NoList below all claims in last three years with (1) Date of Loss (2) Amount of Claim (3) Type of Claim (4) Open/Closed(Page 6 of 6)Completed form to be returned to Wilma Miller – 18936 N. Dale Mabry Hwy., Tampa, FL 33548 – Phone Number (813) 3650987 or 800-741-1955 - Fax 813/830-7870 or e-mail to wilma@integrityfirst.cc.
Church Property & Casualty Insurance Application Completed form to be returned to Wilma Miller - 18936 N. Dale Mabry Hwy., Tampa, FL 33548 - Phone Number (813) 365-0987 or 800-741-1955 - Fax 813/830-7870 or e-mail to wilma@integrityfirst.cc. Please return completed application to: Wilma Miller Insurance - Morrow Insurance Group
