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Fire Destroys Central Union Church Preschool On October 22, an early morning fire destroyed much of the building that is home to the ... Details...

Camp and Bonfire Safety Tis the season! No, not Christmas yet, but gathering around the ole bonfire! The warmth and ... Details...

Carl J. Kotheimer Joins the UCCIB Read the details of our newest employee and what it means to our clients here Carl Kotheimer ... Details...

Protecting Your Church from Lightning Early Monday (June 16th), more than 36,000 residents in 26 communities had been evacuated from their ... Details...

Christmas Safety What a beautiful time of year! Let's keep those sentiments coming and keep the hazards of the Season ... Details...

Proposal Request

This worksheet is for an estimated indication of premium, subject to change based on applicable, completed applications. Coverages will not be bound without complete applications. You may not be able to answer all of these questions. Please fill in all that you know or you may click the “I Need Help Filling This Out” on the right and your local agent will be in touch to assist you.

General Information

Church Name
Church Address
Contact Name
Phone
Fax
Email

Property Description

Sanctuary
Building Replacement Value
Contents Replacement Value
Construction Type		Frame Joined Masonry Non-Combustible/Fire Resistive
Area Square Foot
Age
% Of Building W/Auto Sprinklers		25% 25% 50% 75% 100%

Burglar Protection		None Central Station Local Alarm More

Fire Protection		None Central Station Local Alarm More

Fellowship Hall
Building Replacement Value
Contents Replacement Value
Construction Type		Frame Joined Masonry Non-Combustible/Fire Resistive
Area Square Foot
Age
% Of Building W/Auto Sprinklers		25% 25% 50% 75% 100%

Burglar Protection		None Central Station Local Alarm More

Fire Protection		None Central Station Local Alarm More

Parsonage
Building Replacement Value
Contents Replacement Value
Construction Type		Frame Joined Masonry Non-Combustible/Fire Resistive
Area Square Foot
Age
% Of Building W/Auto Sprinklers		25% 25% 50% 75% 100%

Burglar Protection		None Central Station Local Alarm More

Fire Protection		None Central Station Local Alarm More

Storage Building
Building Replacement Value
Contents Replacement Value
Construction Type		Frame Joined Masonry Non-Combustible/Fire Resistive
Area Square Foot
Age
% Of Building W/Auto Sprinklers		25% 25% 50% 75% 100%

Burglar Protection		None Central Station Local Alarm More

Fire Protection		None Central Station Local Alarm More

School
Building Replacement Value
Contents Replacement Value
Construction Type		Frame Joined Masonry Non-Combustible/Fire Resistive
Area Square Foot
Age
% Of Building W/Auto Sprinklers		25% 25% 50% 75% 100%

Burglar Protection		None Central Station Local Alarm More

Fire Protection		None Central Station Local Alarm More

Garage
Building Replacement Value
Contents Replacement Value
Construction Type		Frame Joined Masonry Non-Combustible/Fire Resistive
Area Square Foot
Age
% Of Building W/Auto Sprinklers		25% 25% 50% 75% 100%

Burglar Protection		None Central Station Local Alarm More

Fire Protection		None Central Station Local Alarm More

Storage
Building Replacement Value
Contents Replacement Value
Construction Type		Frame Joined Masonry Non-Combustible/Fire Resistive
Area Square Foot
Age
% Of Building W/Auto Sprinklers		25% 25% 50% 75% 100%

Burglar Protection		None Central Station Local Alarm More

Fire Protection		None Central Station Local Alarm More

Liability Exposures

Vacant Land
		please enter the number of acres

Church Members
		please enter the number of members

Child Care
		please enter the number of children

School
		please enter the number of children

Employees
		please enter the number of employees

Worker's Compensation (only if line is to be quoted)

Job Site 1
State
Class Code
Job Title or Description
Annual Payroll
# Part-Time Employees
# Full-Time Employees

Job Site 2 (only if in more than one location)
State
Class Code
Job Title or Description
Annual Payroll
# Part-Time Employees
# Full-Time Employees

Job Site 3 (only if in more than one location)
State
Class Code
Job Title or Description
Annual Payroll
# Part-Time Employees
# Full-Time Employees



Automobile Liability: (only if line is to be quoted)

Automobile 1
Model Year
Make & Model
VIN
Cost New
Comprehensive		yes no
Collision		yes no

Automobile 2
Model Year
Make & Model
VIN
Cost New
Comprehensive		yes no
Collision		yes no

Automobile 3
Model Year
Make & Model
VIN
Cost New
Comprehensive		yes no
Collision		yes no

Automobile 4
Model Year
Make & Model
VIN
Cost New
Comprehensive		yes no
Collision		yes no

Current Insurance: (optional but completion is appreciated)

Carrier
Annual Premium
Coverages
Umbrella		yes no
If Yes Limit
Abusive Acts		yes no

verification
please type the image into the box above

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