CHURCH INSURANCE QUOTE

Cooper, Simms, Nelson, & Mosley World Wide Web Site Online Insurance Application


		IMPORTANT NOTICE: Please note that no coverage can be bound using e-Mail, the Internet, or by leaving a voice mail message. All requests must b conducted through our agency with signed applications.


Toll Free: 1.877.644.2766 Providing Insurance Since 1934


CHURCH INSURANCE QUOTE		We would like to provide you with a free, no-obligation church insurance quote. Please provide as much information possible for the most accurate quote. This information will be kept confidential and will be used for quote purposes only.

General Information
Name Of Church:
Your name:
Church Address:
City:	State: Zip:
Church Phone:	Fax Number:
Email Address:
Decision Maker :
Home phone:

Structure Information
Type	Construction	Roof	Foundation	Age Of Church
				yrs.
		Age of roof: yrs.

Features
Bathrooms	Basement	Deck/Porch/Patio
# of Full: # of Half:	Sq. Ft.:	Deck Sq. Ft.: Porch Sq. Ft.:

Additional Features
Heating System	Central Air	Fire Sprinkler System	Security Alarm	Fire Alarm	Smoke Detector
	Yes	Yes			Yes

Property Questions If the Church building is over 25 years old, please answer the following:
Year Electricity was updated: Is it on circuit breakers?:		Yes No
Year Plumbing was updated: Copper or Galvanized plumbing?:		Copper Galvanized Other:
Year Building was last re-roofed:

Secondary Property Questions ( Fill out if there is a secondary building on the property ) (If there is more than one secondary building to be insured on the property, please use the Additional Comments section at the bottom of this form to provide more information )
Age of building /Year Built:	Type of building construction:	Number of stories:	Square feet:	How is this building used?
			sq. ft.
If the building is over 25 years old, please answer the following:
Year Electricity was updated: Is it on circuit breakers?:		Yes No
Year Plumbing was updated: Copper or Galvanized plumbing?:		Copper Galvanized Other:
Year Building was last re-roofed:

Secondary Building -- Additional Features
Heating System	Central Air	Fire Sprinkler System	Security Alarm	Fire Alarm	Smoke Detector
	Yes	Yes			Yes

Liability Questions
Please provide information on previous insurance carrier:
Previous Ins. Carrier:	Policy number:	Prior premium:	Policy renewal date:
		$
Please provide information about your Church:
# Buildings:	# Playgrounds / Sports Fields:		Projected annual Church payroll:
			$

Coverage Limits
Building:	Contents (equipment, inventory, supplies, etc.):		Aggregate Limit:
$	$
Musical Instruments:	Glass or signs:	Occurrence Limit:	Medical Expense Limit:
$	$
If Glass Coverage is needed, please provide dimensions:
Please list other coverages you may need:

Miscellaneous Information
Name of Additional Insured (Landlord):
Mailing Address:
City:	State: Zip:

Additional Comments

Please give any additional comments you feel appropriate for this quotation. If you have additional information where there was not enough fields above, please enter them here.

Please click on the "Submit Quote" button to send your quote request.
One of our representatives will respond to your submission as soon as possible.