Glidewell Investments & Insurance Group, Inc.

STAFF / DEPARTMENT DIRECTORY

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Church Insurance Quote

Please complete the following form and submit. If your church qualifies for our program and we have received adequate information we will provide a quote in the preferred format that you mark below.”

ACCOUNT INFORMATION

Church Name:

Phone:

Address:

Fax:

City:

Web Address:

State:

Contact Name:

Zip Code:

Contact Phone:

Contact Email:

Preferred Method of Contact:

Contact Info:

Time of Contact:

POLICY INFORMATION

Agent Name:

Risk Type:

Policy Effective Date:

Additional Comments:

PROPERTY INSURANCE COVERAGE

Deductible:

LOCATION INFORMATION

Address:

Inside City Limits:

County:

Feet to Hydrant:

Miles to Fire Station:

BUILDING

Occupancy:

Do you have more than one building?

	Building	Contents
Limit ($)

Is this building used exclusively as a dwelling?

CONSTRUCTION TYPE

Choose one to three construction types. (Note that Joisted Masonry does not include Frame with Veneer)

The smallest percentage for any type is 33% for two-construction buildings, and 10% for three-construction buildings.

	Frame	%
	Frame / Brick Veneer	%
	Joisted Masonry	%
	Noncombustible	%
	Masonry Non-combustible	%
	Modified Fire Resistive	%
	Fire Resistive	%
		(Total of Percentages)

ADDITIONAL BUILDING INFORMATION
Sprinkler coverage?
Year Building Built:
Is the building protected by alarms?
Type of Alarm?
Year Roof was built/updated?

MECHANICAL INSTALLATION INFORMATION

Does this building have a heating/cooling system?

	If yes,
	What year was it installed or last updated?	(YYYY)
	Does it meet local building codes?

Does this building have plumbing?

	If yes,
	What year was it installed or last updated?	(YYYY)
	Does it meet local building codes?

Does this building have an electrical system?

	If yes,
	What year was it installed or last updated?	(YYYY)
	Does it meet local building codes?

GENERAL LIABILITY
General Occurrence Limit ($):
Premises Medical Payments Limit ($):
Number of Employees:	(Full- and Part-time)

LIABILITY CLASSIFICATIONS
Church:	Square Feet

OTHER LIABILITY COVERAGES

Sexual Acts

Sublimit ($):
Does applicant currently have a screening program in place?

Clergy/Lay Counseling

# of Clergy:
# of Trained Lay Counselors:

Do you sponsor any athletic activities?

Do you own or lease your facility?

By selecting "Submit" below, you agree to allow one of our representatives to contact you in the manner you selected. We appreciate your interest and look forward to assisting you with your submission.

Securities offered through SIS Financial & Insurance Services.
777 108th Ave. N. E., Bellevue, WA 98004, Tel: (800) 469-7667
Glidewell Investments & Insurance Group, Inc., is not a subsidiary or an affiliate of SIS Financial & Insurance Services