CHURCH SURVEY. Current carrier Renewal date Current premium. Describe Business Activity. Named Insured DBA

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1 CHURCH SURVEY Agent/Account Manager Quote needed by Current carrier Renewal date Current premium Describe Business Activity APPLICANT Named Insured DBA Business entity: Individual Partnership Corporation LLC Other (describe) Mailing Address w/county Contact Person Business Phone Cell Phone: FEIN or SS# Date business started If new, provide details of Business Experience Five year loss history (complete Loss History Statement below) Website Any bankruptcies, tax or credit liens against the applicant in the past five (5) years? Yes No Verbal Disclosure when collecting Social Security Numbers: In connection with this application for insurance, we may review your credit report to obtain and use an insurance loss evaluation score which is based on credit related characteristics. We will use a third party in connection with the development of your insurance loss evaluation score. Entry of the SS# on this survey confirms the owner s acceptance to proceed in cases where the info is needed. PROPERTY (Use a separate Property section to provide details for every building where ANY Property coverage is needed) Street, City, County, State, ZIP (if different than mailing) Inside city limits? Yes No Distance from fire Hydrant? Distance from Fire Dept? Prot. Class Applicant is TENANT OWNER of the building? -Triple net lease? Yes No If you insure the building, in whose name is the Bldg deeded? Year Built Renovation dates if over 25 years: Roof Plumbing Electrical Heating # of Stories: Construction type: Frame Joisted Masonry Masonry Non-comb Non-comb Fire Resistive Total Bldg Sq Ft Your Sq Ft % Vacant Sprinklered % List other Bldg occupants Current Building coverage $ Current deductible? Is there a basement? Business Personal Property$ (furniture, inventory, etc.) Restaurant Equipment $ (If building coverage is included, add this to the BLDG Limit when quoting) Tenants Betterments & Improvements $ (Build-out performed by tenant to customize leased space)

2 LIABILITY Limit Needed $ Number of owners # Employees - Full Time Part Time (do not include owners as Employees, FT or PT) Payroll $ (Do not include owner salaries in payroll) Annual Gross Receipts (including donations) $ LOSS HISTORY STATEMENT I,, have owned/operated for the past years. To the best of my knowledge the CLAIMS HISTORY for my company is as follows: Check if No Known Losses Approx. Date Description/Type of Loss Approx. Amount Paid I attest that, to the best of my knowledge, the information provided for this survey is correct. I understand that premiums quoted for my business will be based on the claims history information I have provided above, and that premiums may change based on a verified loss run from my current insurance carrier(s). Applicant Signature Date As you leave the info gathering appointment you should have: Completed and signed Survey and Supplemental App Pictures Dec pages when possible Vehicle List and Driver List Signed Survey with Loss History Statement and Loss Run Request forms Name, phone, and of Contact Person if other than the business owner

3 Effective Date: RELIGIOUS INSTITUTIONS SUPPLEMENTAL APPLICATION Applicant: Property Information PLEASE PROVIDE A PHOTO OF EACH PREMISES 1. Has the Religious Institution operated at the same location for at least 5 years? 2. Current number of members: 3. Previous year s number of members: 4. Are any of the buildings on Historic Register? 5. Have any lightning-related losses ever occurred? 6. Are steeples protected by a lightning protection system? 7. Is the entire building protected by a lightning protection system? 8. Date the lightning protection system was lasted inspected by a lightning specialist or certified electrician: 9. What type of cooking equipment is in the building? Residential appliances: Ranges Refrigerators Microwaves Commercial appliances: Commercial cooking ranges Steamers Pressure cookers Deep fat fryers) 10. If commercial appliances are used, are the following protective devices in place? * Hood and duct systems? Yes No * Automatic extinguishing system covering all cooking surfaces, hoods and ducts? Yes No If yes, how frequently is it cleaned by an independent contractor? 11. Is stained glass covered by a protective covering (wire, glass, plexiglass or screens)? 12. What type of organ is on the premises? What is its estimated value? 13. Money, Securities and Stamps coverage provided on CP 7521 provides increased limits on 5 stipulated holidays during the year when excess receipts are anticipated. Please list these holidays below. (Refer to CP7521) Automobile Information (complete if owned coverage is desired) YES NO ATTACHED PHOTOGRAPHS (SIDE VIEW) OF ALL BUSES OVER 10 YEARS OLD 14. How are the vehicles used? Do they provide any regular transportation services for the elderly, shut-ins day care. etc? 15. Are written procedures of vehicles maintenance, vehicles usage and qualified operations in place? 16. How frequently are groups transported over a 50-mile radius? 17. Are all drivers at leasst 21 years of age? 18. Do all drivers who operate buses with a seating capacity of 16 or more have commercial driver s licenses (CDL)? FORM /05 Page 1 of 6

4 Religious Institutions Liability Information (complete is coverage is desired) 19. Does the Religious Institution maintain an open door policy allowing 24-hour access? If yes, is it supervised at all times? 20. Does the religious Institution operate, sponsor or have involvement in: Colleges or School? (other than Sunday School or Bible Programs) Retreats or Summer Camps? Shelters or Missions? Rehabilitation Programs or Crisis Centers? Soup Kitchens? Adult Day Care? TV or Radio Broadcasting (other than Sunday School or Bible Programs)? White Water Rafting or Canoe Trips? Horseback Riding? Snow/River Tubing? Other Hazardous Activities Not Listed? Describe: Please explain any yes responses 21. Has Religious Institution entered into a contract where they have agreed to hold harmless and indemnify another party? 22. Does a day care not affiliated with the Religious Institution use the premises? If yes, is a Certificate of Insurance obtained listing the Religious Institution as an additional insured? 23. Please list any uninsured organizations who use the premises: Fund Raising Supplemental Information 24. Does the Religious Institution operate or sponsor: Bingo Games? Carnivals or Fairs? Amusement-type Rides? Fireworks? Other? Please explain any yes responses 25. Are certificates of insurance obtained listing the Religious Institution as an additional insured for all yes responses in question 23? If no, explain FORM /05 Page 2 of 6

5 26. Does the Religious Institution own/operate a cemetery? If yes provide location and number of acres: Religious Institutions Day Care operation by Religious Institution (complete if applicable) YES NO 26. State License Number Expiration Date 27. Number of children licensed for: Number of children at this location at any one time: - How long has applicant been licensed? - Has the license ever been revoked or suspended? - If yes, why? - The applicant is a: Church Private School Public School Other - If Other, explain: - Day care facility located at: Church Commercial Bldg. School Other - If Other, explain: 28. Is the operation non-profit? 29. Number of years applicant has been in this business? 30. What specialized training does applicant have? 31. What specialized training do staff members have: 32. Describe in-house training given to all staff in day care operations: 33. Describe playgound equipment (state if none): 34. Is the facility surrounded by a fence? What is the ground cover in the outside play area? 35. Are there any water exposures (i.e. pools, lakes, streams)? If yes, please describe, including a description of any fences or other means of limiting access: 36. Are fire drills conducted regularly? 37. Which safety devices are present? fire extinguisher manual fire alarms electrical outlets protected w/ safety caps 38. Are there any pets at the location? 39. Have all staff members received an employment medical examination? 40. Have all staff members received first aid treatment training? 41. Are all employees investigated before hiring? 42. Does this include checking all references and obtaining a police report? 43. Does the applicant s employment application include questions about whether the individual has ever been convicted of any crime, including sex-related or child abuse-related offenses? 44. Are personal interviews conducted with each applicant? FORM /05 Page 3 of 6

6 YES NO Religious Institutions 45. Does the plan of supervision monitor staff in day-to-day relationships with children? 46. Has the applicant had an incident which resulted in an allegation of sexual abuse at his or her facility? If yes, explain: 47. Is corporal punishment practiced? -If yes, attach copy of written procedure. 48. Do employees/employers use their vehicles to transport children? 49. If employees/employers transport children, are certificates of insurance required showing liabilitylimits? 50. Is there a formal, written drop-off/pick-up procedure with designated individuals for child pick-up? 51. Are permission slips required if someone other than the designated individual picks up the child? 52. Are there late pick-up procedures? 53. Are there first aid treatment kits at the facility? 54. Are emergency phone numbers for both parents and physician maintained and updated for each child? 55. Are records maintained for each child showing any health or dietary problems? 56. Are any mentally, emotionally or physically handicapped children cared for? Explain the extent of the handicap and special care arrangements: 57. Is any medicine given to children? 58. Are medicines kept in locked cabinets? 59. Is there written permission from the parent to administer medication? 60. Are there any licensed teachers? 61. Do any children stay overnight? 62. Is there regular transportation of students? 63. Are field trips taken? 64. Is written permission required for field trips? 65. Is after-school care provided? If yes, how do children get to the facility? Explain: 66. Has the facility ever been found to be in violation of any health, safety or building codes? Explain: The staff breakdown by age of child is: Staff for each children 0-1 years of age Staff for each children 2-3 years of age Staff for each children 3-5 years of age Staff for each children 6 years of age Staff for each children 7 years of age Total number of staff: 67. Has similar insurance ever been cancelled or nonrnewed? If yes, explain: FORM /05 Page 4 of 6

7 Religious Institutions YES NO Personal Counseling (complete if coverage is desired) 68. Number of clergy: 69. Is clergy ordained? 70. Does clergy hold a degree from a Bible College/Divinity School? If no, please provide extent of education 71. Has clergy received formal training in counseling? 72. Are individuals other than clergy involved with counseling? If yes, please explain and list namesd of non-clergy counselors. 73. Does the Board of Directors conduct background and reference checks of individuals other than clergy performing counseling? 74. Do they advertise and offer counseling to the general public? 75. Is a fee/donation/charge required for counseling services? 76. When does the Religious Institution refer individuals to outside professional help? 77. Are there any past or present Personal Counseling claims or suits? 78. Does the Religious Institution have knowledge of any circumstance which may result in a Personal Counseling claim or suit? 79. Previous Personal Counseling Liability Insurance: Name of Insurer: Limit of Liability: Expiration Date: Directors and Officers/Administrative Liability (complete if coverage is desired) 80. The Religious Institution has operated continuously since: 81. Is the Religious Institution s financial condition examined by an independent auditing firm, CPA or an internal financial committee? 82. Are legal matters referred to an outside law firm or qualified attorney? 83. Is the Religious Institution a diocese, synod, presbytery or other similar church governing body? 84. Are there any past of present claims or suits against the Directors and Officers of the Religious Institution? 85. Does the Religious Institution have knowledge of any circumstance which may result in a claim or suit against the Directors and Officers Liability Insurance? 86. Previous Directors and Officers Liability Insurance: Name of Insurer: Limit of Liability Expiration Date: FORM /05 Page 5 of 6

8 Automobile Religious Institutions 87. a. Do you own or operate any 15-passenger vans? b. If yes, are you aware of the National Highway Traffic Safety Administration s rollover warning to users of 15-passenger vans? c. How are you addressing this issue? d. Do the drivers of the 15-passenger vans have a commercial drivers license (CDL)? e. Do you allow anyone to the drive the 15-passenger vans or only designated individuals? f. Describe your driver selection process for drivers of the 15-passenger vans: g. Describe your driver training program for drivers of the 15-passenger vans: h. Are drivers under the age of 25 allowed to operate the 15-passenger vans? Applicant s Signature Producer s Signature FORM /05 Page 6 of 6

9 LOSS HISTORY REQUEST Date: To: Insurance Company Attn: Fax: or Re: Loss History Request Policy Number Policy Number Policy Number I hereby request and authorize the release of five years loss history (or since inception if less than five years) to IHT Insurance Agency. Please supply this information to the following Thank you for your assistance, X SIGNATURE TITLE