CHURCH INSURANCE QUOTE REQUEST FORM

For a fast, personalized quote, fill out the applicant information and select "Submit" to complete the Church Insurance Quote Request.  
Applicant Information
Church Name:
Church Address:
City:
State:
Zip Code:
Phone:
Number of Members:
Denomination:
Effective Date of Current Policy:
Your Name:
Relationship:
Your Home Phone:
Your Work Phone:
E-mail:
Best way to contact:
Has insurance been declined or non-renewed in last 3 years? Yes      No
Any claims in the last 3 years? Yes  No
Does the Church rent or own the property? Rent     Own   
Approximate square footage of Church and any connected buildings:
Year Church built:
Construction Type:
Age of Roof:
Current Building Insured Amount:
Current Contents Amount:
Does the Church own any additional properties? Yes     No
If yes, please provide following:  
Address:
City
State:
Zip:
Approximate square footage and any connected buildings:
Year built:
Construction Type:
Age of Roof:
Usage:
Current Building Insured Amount:
Current Contents Amount:
Does the Church own a parsonage? Yes     No
If yes, please provide following:  
Address:
City:
State:
Zip:
Approximate square footage and any connected buildings:
Year built:
Construction type:
Age of Roof:
Current Dwelling Amount:
Current Amount Insured: 
Boiler & Machinery Coverage Desired: Yes     No
With Boilers: Yes     No
Musical Instrument Coverage Desired to Cover Instruments which leave the Church premises for use: Yes     No
Instruments:
Total Amount of Coverage:
Does the Church have a Day Care? Yes     No
Ages of Children:
Hours of Operation:
Does the Church have a School? Yes     No
School grades:
Number of Children in K-8 Program:
Number of Children in 9-12 Program:
Hours of Operation:
Workers Compensation Coverage Desired: Yes     No
Number of Church Employees Including Pastor:
Total Annual Compensation for Pastors, secretaries, choir director, organist, administrative assistant, etc.
Total Annual Compensation for All Other Church Employees:
Number of School Employees:
Total Annual Compensation for all Professional School Employees:
Total Annual Compensation for All Other School Employees:
Is there any additional information you would like us to know?
 

Thank you for taking the time to complete the Church Insurance Quote Form.  You will hear from your Joseph White Insurance consultant within 36 hours.

Joseph White Insurance Agency
5180 Parkstone Dr., Suite 250
Chantilly, VA 20151
 		Tel:  703-968-0800
Fax: 703-968-0988
Toll Free: 1-888-280-4639