Church Program

First Named Insured

Mailing Address

City
State
ZipCode		Click here to search for the Zip Code
Federal Employer ID
First Named Insured Phone
DUNS #	- -	If known; otherwise please leave blank
Effective Date	/ /
Business Website(URL)		If known; otherwise please leave blank
State of Domicile


Agency Contact Name
Agency Contact Phone		Ext:

Agency Name	Isner Insurance Associates, Inc.
Business Type

Full Time Employees
Part Time Employees

Year Business Was Established or Acquired By Current Owner

Seating Capacity

Select Lines of Business To Be Included In This Policy	Property		General Liability
	Automobile		Umbrella

Boiler? Yes No

Contact Name

Phone

Ext

Email Address

Accounting Records Contact

Name

Phone

Ext

Email Address

Building Deductible:
Personal Property Deductible:
Personal Property Valuation:
GL Occurrence/Aggregate Limit:
Property Damage Deductible:
Products and Completed Operations Aggregate:
Personal and Advertising Injury Limit:
Tenants Legal Liability Limit:
Medical Expenses:

Location # 1
Address		Provide physical location. Address lines must not contain PO Box, C/O, DBA, or T/A.
Address 2

City
State

Zip code

County

Interest Type

Is distance to responding fire station less than 5 miles?	Yes No
Is property within 1000' of commercially navigable body of water?	Yes No

Class

Does the above class best describe the operations at this location?

Yes No

Location # 1

Address
Address 2

City
State

Zipcode

County

Territory

Interest Type

Is distance to responding fire station less than 5 miles?	Yes No
Is property within 1000' of commercially navigable body of water?	Yes No

Class

Does the above class best describe the operations at this location?

Yes No

Location #1

Is there a kitchen facility at this location?

Yes No

1A.

If Yes, is it equipped with a commercial cooking unit?

Yes No

1B.

If Yes to above, is the kitchen equipped with a hood and duct system meeting NFPA #96?

Yes No

1C.

If Yes to above, are the automatic extinguishing system and hood and duct system inspected and maintained semiannually?

Yes No

1D.

Is the kitchen equipped with a fire extinguisher and/or smoke alarm?

Yes No

1E.

Is the fire extinguisher and /or smoke alarm inspected at least annually?

Yes No

Is there a steeple?

Yes No

2A.

If yes, is it protected by an approved UL Lightning System?

Yes No

Has risk had 2 or more V&MM or Fire Claims in the past 3 years?

Yes No

Building Limit:
Personal Property Limit:
Building Valuation:
Construction Type:
Year Built:
Protection Class
Total Area - All Floors excluding Basement:
Number of Stories:
Number of Basements:

Less than 1000' from Hydrant?

Yes No

Is Building Sprinklered?	Yes No
Fire Alarm Type:	Central Station Local None
Burglar Alarm Type:	Central Station Local None

Improvement Year Wiring:
Improvement Year Plumbing:
Improvement Year Heating:
Improvement Year Roof:

Comprehensive Renovation Year:

Any Loss Payees/Mortgagees?

Yes No

Location # 1 , Building # 1

1) What percentage of the Total Area of the building does the applicant occupy?

2) What percentage of the building is vacant or unoccupied?

3) Other than the applicant, what percentage is occupied by one or more of the following:

	Apartment / Habitation
	Auto Service/Repair
	Bars, Pubs or Taverns
	Grocery Store/Supermarkets
	Offices
	Restaurants
	Retails Stores (Other than listed above)
	Any Other Occupancies not described above

TOTAL (1+2+3)

4) Does the applicant require all tenants to carry Property and

General Liability Insurance?

Yes No

4a) If yes, does the applicant collect and maintain Certificates of
Insurance?	Yes No

Location #1 , Building #1

	Limit	Deductible
Boiler Coverage
Building Ordinance (Coverage B & C)
Earthquake
Glass Deductible Buyback (Extended Glass)
Household Personal Property
Increased Building Replacement Cost (+25%)

	Business Income & Extra Expense Exclusion
	Employee Dishonesty Exclusion
	Forgery or Alteration Exclusion
	Money & Securities Exclusion
	Off Premises Power/Water Failure Exclusion
	Theft of Personal Property Exclusion

	Limit	Deductible
Accounts Receivable
Animal Bailee Coverage
Animal Theft

Does the Applicant have any prior Insurance?	Yes No
Have there been any claims or occurrences within the last 5 years that may give rise to claims?	Yes No
Do you have hard copy loss runs?	Yes No
Any Other Named Insureds with Common Majority Ownership?	Yes No
Is the primary location address different from the mailing address?	Yes No