Fillable Religious Institution Supplemental Application (Risk Placement Services, Inc.)

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Religious Institution Supplemental Application (Risk Placement Services, Inc.)

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Core Product Religious Institutions Supplemental App v.Jan 2011
Page 1 of 2
Religious Institution Supplemental Application
Please answer all questions completely. If there is insufficient space to complete an answer, please
continue on a separate sheet indicating the question number. This Application must be completed, signed,
and dated by an officer, director or equivalent executive of the religious organization. Please include all
attachments referenced throughout the Application and complete any supplemental pieces referenced
within the Application. Please type or print.
The information requested in this Application is for underwriting purposes only and does not
constitute notice to the Insurer under any Policy of a Claim or potential Claim. All such notices must be
submitted to the Insurer pursuant to the terms of the Policy, if and when issued.
Name of organiza
tion:__________________________________________________________
Website address (URL): www.____________________________________________________
1. Church denomination:______________________________________________
2. Number of Church Members:_________________________________________
3. Number of clergy:__________________________________________________
4. Total number of full time paid staff, excluding clerical/secretarial:____________________
5. Are any dwellings owned by the church?
Yes No
If yes, is housing provided for clergy only?
Yes No
6. Does any building have either stained glass, statuary or other fine arts affixed to the building?
Yes No If yes, attach a schedule of fine arts with values for each item.
7. Does your church offer bingo regularly? Yes No
If yes, how many people attend annually?_______________
If yes, attach a completed Special Event & Bingo Supplement.
8. Does your church have a licensed school (K-12)?
Yes No
If yes, attach a completed Educational Services & School Application.
9. Does your church offer childcare (other than during services)?
Yes No
If yes, complete the Childcare Supplement.
10. Is your church kitchen equipped with commercial cooking equipment?
Yes No
If yes, complete Commercial Cooking Supplement
11. Does your church offer youth group activities? Yes No
If yes, attach a list of activities scheduled for the year.
12.
Does your church air TV or radio programs; print or record material for public distribution or sale; or sell
books, tapes, CDs or other commercial material? Yes No
If yes, complete the Media Supplement.
13. Does your church provide ”meals on wheels” services? Yes No
14.
Is Pastoral Counseling Liability coverage desired? Yes No
If yes, please provide the number of FTE Pastoral Counselor
s ___________
Core Product Religious Institutions Supplemental App v.Jan 2011
Page 2 of 2
15. Does your staff include any of the following types of professionals?
Accountants, Attorneys, Architects, Engineers or Financial Advisor/Consultant
If you would like coverage for these individuals please complete the appropriate Supplemental Miscellaneous
Professional Application.
16. Indicate any of the following types of events that you sponsor or participate in:
Complete a Special Event Supplement for each event indicated.
None of the following apply
Event includes:
Estimated attendance of more than 300 persons Haunted House
Aircraft or watercraft(motorized or not) Home Tours
Animals Fireworks sales or fireworks shows
Mechanical or non-mechanical entertainment devices( i.e. , inflatable boucers or slides)
Athletic Participation(i.e., rope courses, climbing walls , marathons, etc.)
Parades - participation or sponsorship Use of Motorized vehicles of any type
17. Provide the following: Employees Volunteers
a) Is unsupervised contact allowed with clients? Yes No Yes No
b) Is education verified?
Yes No Yes No
c) Are Personal referrences checked?
Yes No Yes No
d) Is a written application required?
Yes No Yes No
e) Is State 10-digit fingerprint criminal record check required?
Yes No Yes No
f) Is Federal 10-digit fingerprint criminal record check required?
Yes No Yes No
g) Are all controls indicated in d-f required prior to any client
contact? Yes No Yes No
h) How long are records kept documenting all screening activities
Outlined above? ___________ ___________
18. Does your organization rent or lease any vehicles on a short term basis? Yes No
If yes, what is your annual vehicle rental expense?_____________________
19. Is non-owned auto liability coverage desired?
Yes No
20. Does the church formally lease any space to others? Yes No
If yes, please indicate:
Area of leased space:____________ To whom is space leased?___________________________________
21. Does the church operate their own Cemetery, Mausoleum, or Columbarium? Yes No
If yes, please indicate: Annual Internments___________ Cemetery acres______________
22. Does church sponsor overnight trips which include children under the age of 16?
Yes No
If yes, please describe: ____________________________________________________________________
23. Have you had any claims and/or circumstances that have not been previously reported?
Yes No
If yes, please attach detailed claim information with the date of the loss or occurrence, the status, the amount
reserved or paid and a description of the claim or allegation.
The undersigned represents that all statements and answers to questions are true, complete and accurate and that
there has been no suppression or misstatement of fact.
THE APPLICANT ACCEPTS NOTICE THAT HE/SHE IS REQUIRED TO PROVIDE WRITTEN NOTIFICATIONS TO
THE COMPANY OF ANY CHANGES IN THE RESPONSES GIVEN TO THIS APPLICATION THAT MAY HAPPEN
BETWEEN THE SIGNATURE DATE BELOW AND ANY PROPOSED EFFECTIVE DATE.
The undersigned is an authorized representative of the applicant and certifies that reasonable enquiry has been
made to obtain the answers to questions on this application. He/She certifies that the answers are true, correct and
complete to the best of his/her knowledge.
Date Signed Signature of Applicant ____________
Print Name and Title ______________________________________
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Religious Institution Supplemental Application (Risk Placement Services, Inc.)

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Completed 23 November 2020

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