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Non-Profit Insurance Quote Form
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* Indicates required question
Church Name - Non-Profit Name
*
Your answer
Church Phone Number
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Your answer
Church Email Address
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Your answer
Church Website Address
Your answer
Contact name
*
Your answer
Contact - -Phone Number
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Your answer
Can We Text You About Policy?
Yes
No
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Contact - Email Address
*
Your answer
MAILING ADDRESS - Street - City - Zip Code
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Your answer
Physical Address - Street
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Your answer
City
*
Your answer
State
*
Your answer
Zip
*
Your answer
County
*
Your answer
FEIN Number
*
Your answer
When did the Church/ Non-Profit Start? PLEASE GIVE FULL DATE
Your answer
Please choose ALL the Insurance Products You Will Need Quoted.
General Liability
Content Coverage (Sound system, Chairs, Bibles, etc.)
Building Insurance
Commercial Auto
Worker's Compensation
Umbrella
Group Health
Group Life
List Each Building & Square Footage: Sanctuary, Fellowship Hall...etc..
Your answer
Number of Staff/Employees
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Your answer
Annual Receipts / If New Estimated
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Your answer
Average Weekly Attendance?
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Your answer
Do you currently have coverage?
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Yes
No
Required
Renewal Date OR Requested Effective Date
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Your answer
Current Insurance Company
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Your answer
Any Claims in last 3 years?
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Yes
No
Required
PLEASE LIST Additional Insured? Name & Address
Your answer
Additional Info - Notes
Your answer
Please Have Current Policy Declaration Pages Ready For Agent. You Can Email Them to the Email listed
*
Yes
No
Send Information to
Choose
Trey Himes - thimes@melhimesinsurance.com
Angela Galorneau - agalorneau@melhimesinsurance.com
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