CHRUCH QUOTE FORM Date: Quote Taker's name: Email Address: Name: Are you set-up as a Non-Profit Corporation OR LLC City: Country: ST: Zip Code: Contact Name: PH#: FAX#: Date Congregation Founded: HRS of Operation: FED ID#: Current INS Comp: Expiration Date: Current Premium:$ Claims & Loss History: PROPERTY SECTION BUILDING: CONTENTS: Sign Coverage Needed: any Cooking on the premises: Yes No Build.Conts.Type: YR Built: Built SQ FT: Central Station Alarm : Yes No Sprinkler System: Yes No LIABILITY SECTION Liability Limits : Do employees use their own auto for Church's business? Yes No Days and Hours of Day Care Is there a DAY CARE CENTER on premises? Yes No If yes, is it operated by the Church? Yes No Is Day Care a state or county licensed operation? Yes No Field trips taken by Day Care? Yes No If yes, describe activities and indicate frequency: Any church facilities used by outsiders? Yes No If yes explain: Playground on Premises? Yes No If yes, Is it Fenced? Yes No Would you like the following coverage added to the policy? Sexual Misconduct: Yes No Spiritual Counseling: Yes No Directors and officers Liability: Yes No