Untitled Document

CGA House of Worship Insurance Application Form
For the fastest and most accurate insurance quote, please provide as much information possible in the form below. This information will be kept confidential and will be used for quote purposes only!

Submitting Information

Business Name:
Contact Name:
Street Address:
City:	State: ZIP:
County:	Email:
Business Phone:	Fax:

House of Worship Name:
Attention:
Street Address:
City:	State: ZIP:
Business Phone:	Fax:
Email:
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.