Fillable Storefront/Community Church Application All States (Access E&S Insurance Services)

Fill Online, Printable, Fillable, Blank Storefront/Community Church Application All States (Access E&S Insurance Services) Form

Use Fill to complete blank online ACCESS E&S INSURANCE SERVICES pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Storefront/Community Church Application All States (Access E&S Insurance Services)

On average this form takes 58 minutes to complete

The Storefront/Community Church Application All States (Access E&S Insurance Services) form is 4 pages long and contains:

  • 1 signature
  • 27 check-boxes
  • 214 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your Access E&S Insurance Services forms online.

BROWSE ACCESS E&S INSURANCE SERVICES FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
You can obtain a quote bY providing the information in Section i - inStant quote below, Subject to the remainder provided prior to binding.
Type of coverage being requested: q General liability q Property q Non Profit D&O
SCCP APP 11/11
page 1 of 4
Storefront/Community Church Application – All States
I. INSTANT QUOTE INFORMATION
Instant Quote is only available for accounts with no losses in the past 3 years. If there is loss history, please complete the entire application.
Name of organizaton : ______________________________________________________________________________________________________
Location address: _______________________________________________________ City: _____________________ State: _____ Zip: ________
Mailing address:(if different) _________________________________________________ City: _____________________ State: _____ Zip: ________
Web address: _____________________________________________________________________________________________________________
Description of operations:
Does organization have tax exempt status by the IRS? q Yes q No
Property Section (complete for each building)
Construction: q Frame q Joisted masonry q Non-combustible q Masonry non-combustible
q Modified fire-resistive q Fire-resistive q Other ___________________
Protection class:
Requested cause of loss: q Basic q Special
Requested valuation: q Replacement cost q Actual cash value
Deductible: q $1,000 q $2,500 q $5,000
Coinsurance: q 80% q 90% q 100%
Business personal property limit $ _________________________
Business income and extra expense limit $ _________________
Building owner q Yes q No (If No, skip a-c)
a. Building limit $ _________________________________
b. What year was the building constructed? _________
c. What is the square footage of the entire structure? _____________sq. ft.
General Liability Section
GL limit: q $100,000/$200,000 q $300,000/$600,000 q $500,000/$1,000,000 q $1,000,000/$2,000,000
Pastoral professional limit (not to exceed the GL limit):
q $100,000/$100,000 q $300,000/$300,000 q $500,000/$500,000 q $1,000,000/$1,000,000
Total number of church members: ___________________
Total square footage used for church operations: _________________________________________
Does the organization operate a school (kindergarten or higher)? q Yes q No
Does the organization have a childcare, after school program or day camp operations? q Yes q No
If yes, total number of children: ______________________ (please complete our Child Care Operations Supplemental Application)
Building owner q Yes q No (If No, skip a-f)
a. Total building square footage: ___________________
b. Is any portion of the building leased to commercial tenants? q Yes q No If “Yes,” applicable sq. ft. ____________
c. Does the applicant lease any apartments at this location to others other than clergy? q Yes q No
d. If “Yes,” number of units ________________ applicable sq. ft. ___________________
e. Does the applicant have any apartments or dwellings at this location used as a
residential facility for clergy? q Yes q No
f. If “Yes,” number of units ________________ applicable sq. ft. ___________________
Additional Interests (AI = Additional Insured, LP=Loss Payee, M=Mortgagee)
Name Relationship/Interest Address City, State, Zip AI, LP, M
Non Profit Directors & Officers/Employment Practices Liability Section
Total annual revenue: _______________________________ (If >$2 million attach the most recent 12-month financial statement)
If less than three years in operation, annual revenue: this year : _______ next year: _____________ 3rd year: ___________
Total fund balance (total assets minus total liabilities): ________________________________________
Full-time employees: ______________ Part-time: _____________ Temporary/Seasonal: _______________ Volunteers: _____________
Does the organization perform any operations located outside the U.S.? q Yes q No In existence since: ____________________
USLI.COM
888-523-5545
II. LOSS INFORMATION FOR THE PAST THREE YEARS
Property Coverages q None, or provide detail below.
Year Status Incurred Description
_______ Open/Closed $ ______________ _____________________________________________________________________________
_______ Open/Closed $ ______________ _____________________________________________________________________________
_______ Open/Closed $ ______________ _____________________________________________________________________________
General Liability Coverages q None, or provide detail below.
Year Status Incurred Description
_______ Open/Closed $ ______________ _____________________________________________________________________________
_______ Open/Closed $ ______________ _____________________________________________________________________________
_______ Open/Closed $ ______________ _____________________________________________________________________________
GENERAL LIABILITY
1. Does the organization own or operate a camp or retreat center? q Yes q No
2. Does the organization participate in outdoor camping events or events with bonfires? q Yes q No
3. Does the organization have a gymnasium or recreation center? q Yes q No
4. Does the organization have a pool on premises? q Yes q No
5. Does the organization participate, organize or sponsor any events that include fireworks, firearms, hunting,
water hazards, haunted attractions, hayrides or air shows? q Yes q No
6. Does the organization provide prison ministry services? q Yes q No
7. Does the organization operate a shelter or rooming house? q Yes q No
If yes, total square footage: ____________
(please complete our Social Services - Residential Facilities Application)
8. Does the organization own a cemetery? q Yes q No
If yes, number of acres ____________
9. Does the organization operate a soup kitchen? q Yes q No
If yes, square footage of operations ____________
10. Are all exit signs illuminated on premises? q Yes q No
11. Are there at least two accessible means of egress? q Yes q No
12. Any anticipated construction of new buildings or alterations to existing structures?
(If “Yes,” please provide details separately) q Yes q No
13. Does the organization require commercial tenants to carry general liability insurance with organization named as
an additional insured? q Yes q No
14. Has the organization or any of its past or present directors, officers, trustees, committee members, employees
or anyone acting in a ministerial capacity ever been involved in a lawsuit or claim for sexual abuse, misconduct
or molestation, or has any charge or arrest been made against said person for the same? q Yes q No
15. If there are child-sitting/nursery operations during the services, is there a sign in and sign out procedure for the children? q Yes q No
16. Does the organization have functioning and operational smoke and/or heat detectors in all public areas and units? q Yes q No
ABUSE AND MOLESTATION LIABILITY:
17. Does the organization have a hiring process for employees and volunteer workers that includes questions about
whether the individual has ever been convicted of any crime and involved in any lawsuit, claim or criminal charge
involving sexual abuse, sexual molestation or sexual misconduct? q Yes q No
18. Does the organization require and verify prior employment and personal references on every prospective employee? q Yes q No
19. Except for bona fide counseling sessions, are minors ever left alone with only one adult in any program, service,
event or other church-sponsored activity? q Yes q No
20. Does the organization follow policies or procedures for the proper supervision of employees and volunteers who are
in direct contact with minors and other individuals in all on-site or off-site programs, services, events or other
activities of applicant? q Yes q No
PASTORAL PROFESSIONAL LIABILITY:
21. Does the organization have more than five pastors/clergy on staff? q Yes q No
22. Does the organization offer counseling services for a fee? q Yes q No
23. Does the organization utilize contracted counseling providers? q Yes q No
24. Are church members referred to specialists when appropriate? q Yes q No
25. Are procedures in place to protect the confidentiality of church members? q Yes q No
26. Have there been any prior allegations, claims or suits as a result of counseling services? q Yes q No
HIRED AND NON-OWNED AUTO: q Check if coverage is desired and answer questions a through c
Note: If Hired/Non-owned is checked, limit will equal general liability occurrence limit.
a. Does the organization have a business (or commercial) automobile insurance policy in force or own or
lease autos on a long term basis? q Yes q No
SCCP APP 11/11 - United States Liability Insurance Group
page 2 of 4
b. Does the organization regularly transport people or deliver goods or products? q Yes q No
c. Does the organization require its employees to use their personal automobile to conduct the organization’s
business on a regular basis? q Yes q No
PROPERTY:
27. Does the organization’s property have aluminum wiring (including partial) or knob and tube wiring? q Yes q No
28. Are functioning and operational fire extinguishers readily available? q Yes q No
29. Is there a commercial cooking exposure? (If “Yes,” answer a-c) q Yes q No
a. Is the cooking area, hood and duct system protected per NFPA 96? q Yes q No
b. Is there a deep fat fryer on the premises? q Yes q No
c. What type of approved NFPA 96 extinginshing system is functional and operational q Wet q Dry q NA
30. Are any buildings currently damaged by fire or otherwise? q Yes q No
31. Are any buildings partially constructed? q Yes q No
32. Is this property a seasonal operation? q Yes q No
33. Has the organization had any bankruptcies, tax or credit liens against them in the past five years? q Yes q No
34. Has any officer or board member of the organization been previously convicted of the felony of arson? q Yes q No
35. Is 100% of the electrical wiring on functioning and operational circuit breakers? q Yes q No
Complete the following questions only if special cause of loss is requested for the building:
36. Plumbing system is completly copper or PVC? q Yes q No
37. Electrial system is less than 35 years old? q Yes q No
38. Roofing has been replaced or recoated within the past 10 years for flat; 20 years for shingle or composite;
40 years for metal; 25 years for tile; or 50 years for slate? q Yes q No
NON PROFIT DIRECTORS AND OFFICERS AND EMPLOYMENT PRACTICES LIABILITY
39. Does the organization engage in any disciplinary actions as a result of peer review activities? q Yes q No
40. Does the organization administer or sponsor any insurance programs? q Yes q No
41. Is the organization involved in any accreditation or standard setting activities? q Yes q No
42. Does the applicant have any subsidiaries requiring coverage? q Yes q No
If “Yes,” please complete the Non Profit Subsidiary Addendum (NPSADD).
43. Name and title of individual designated to receive all notices on behalf of the insured: ______________________________________________
Title ________________________________________________________Phone number: _______________________________________________
44. Directors and officers liability Insurance carried:
Insurer Limits of Liability Premium Retention Policy Period
____________________________ ____________________ ____________________ __________________ ____________
45. Does the organization currently carry general liability insurance? q Yes q No
46. Within the last five years, has any inquiry, complaint, notice of hearing, claim or suit been made (including, but not limited to, equal
employment opportunity commission, state human rights boards, municipal, state or federal regulatory authorities), against the
organization, or any person proposed for insurance in the capacity of director, officer, trustee, employee or volunteer of
the organization? q Yes q No
(If “Yes,” please forward a completed USLI supplemental claims application.)
47. Is any person proposed for this insurance aware of any fact, circumstance or situation which may result in a claim against the
organization or any of its directors, trustees, officers, employees or volunteers? q Yes q No
(If “Yes,” please forward a completed USLI supplemental claims application).
Virginia Notice: Statements in the application shall be deemed the insured’s representations. A statement made in the application or in any
affidavit made before or after a loss under the policy will not be deemed material or invalidate coverage unless it is clearly proven that such
statement was material to the risk when assumed and was untrue.
Minnesota Notice: The clause “and/or authorization or agreement to bind the insurance.” is replaced with “Authorization or agreement to bind
the insurance may be withdrawn or modified based on changes to the information contained in this application prior to the effective date of
the insurance applied for that may render inaccurate, untrue or incomplete any statement made with a minimum of 10 days notice given to the
insured prior to the effective date of cancellation when the contract has been in effect for less than 90 days or is being canceled for
nonpayment of premium.”
Colorado Fraud Statement: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company
for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil
damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information
SCCP APP 11/11 - United States Liability Insurance Group
page 3 of 4
to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or
award payable from insurance proceeds shall be reported to the Colorado division of insurance within the department of regulatory agencies.
District of Columbia Fraud Statement: WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of
defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if
false information materially related to a claim was provided by the applicant.
Florida Fraud Statement: You are agreeing to place coverage in the surplus lines market. Superior coverage may be available in the admitted
market and at a lesser cost. Persons insured by surplus lines carriers are not protected under the Florida Insurance Guaranty Act with respect
to any right of recovery for the obligation of an insolvent unlicensed insurer.
Kentucky Fraud Statement: Any person who knowingly and with intent to defraud any insurance company or other person files an application
for insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material
thereto commits a fraudulent insurance act, which is a crime.
Maine and Washington Fraud Statement: It is a crime to knowingly provide false, incomplete or misleading information to an insurance
company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits.
New Jersey Fraud Statement: Any person who includes any false or misleading information on an application for an insurance policy is
subject to criminal and civil penalties.
New York Fraud Statement: Any person who knowingly and with intent to defraud any insurance company or other person files an application
for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information
concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and shall also be subject to a civil penalty not to
exceed five thousand dollars and the stated value of the claim for each such violation.
Ohio Fraud Statement: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an
application or files a claim containing a false or deceptive statement is guilty of insurance fraud.
Oklahoma Fraud Statement: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any
claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.
Pennsylvania Fraud Statement: Any person who knowingly and with intent to defraud any insurance company or other person files an
application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information
concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil
penalties.
Tennessee and Virginia Fraud Statement: It is a crime to knowingly provide false, incomplete or misleading information to an insurance
company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.
Fraud Statement (All Other States): Any person who knowingly presents a false or fraudulent claim for
payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty
of a crime and may be subject to fines and confinement in prison.
Applicant’s signature: ____________________________________________ Title: _________________________ Date: _________________________
If your state requires that we have information regarding your authorized retail agent or broker, please provide below.
Retail agency name: _______________________________________________________________________ License #: ___________________________
Main agency phone number: ____________________________________________________________________________________________________
Agency mailing address: _________________________________________________________________________________________________________
City: ________________________________________ State: __________________ Zip code: ___________________________
SCCP APP 11/11- United States Liability Insurance Group
page 4 of 4
click to sign
signature
click to edit
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

StorefrontCommunity Church Application All States (Access E&S Insurance Services)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 8 January 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document