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Winter Board Form

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Winter Board Form

Legal Name of the Church

FEIN

Entity

LLC
Sole Proprietor
Inc
Non-Profit

Email Address

Phone Number:

Please list additional addresses if any

Website:

Pastor's Name

Pastor's Phone Number:

Contact Name & Title

Contact Phone Number:

to addresses have

Contact Email Address

GENERAL LIABILITY UNDERWRITING INFORMATION – Number of Years in Business

GENERAL LIABILITY UNDERWRITING INFORMATION – Number of Members

Does the church operate a daycare or any other type of business

Yes
No
Not sure
Other

Does the church own a cemetery

Yes
No
Not sure
Other

If so please provide the address

Number of acres for the cemetery

Would you like coverage for your board members

Yes
No
Not sure
Other

If so list the number of members

Annual Revenue if any

Would you like to include Sexual Abuse and Molestation:

Are there any additional locations where you would need General Liability:

Does the church offer any after school programs or summer camps:

Total Square Feet of the church:

How many stories is the church:

Does the property have sprinkler system:

Does the church have any foreign operations ( missionary work / going abroad )

Any prior General Liability claims or Sexual Abuse claims

Any prior General Liability claims or Sexual Abuse claims, If so, please provide:

Date of loss:

Description of loss:

Amount paid out to you:

Are the damages repaired:

Current company name:

Expiration date:

Years of continuous coverage:

LOSS RUNS FROM YOUR CURRENT INSURANCE COMPANY MUST BE PROVIDED (3-5 YEARS)

We request 5 years of loss runs . Please email us these forms mcclainmissions@gmail.com and also lock in these numbers 601-317-0560 or (601) 566-1572

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