Name: Near Me Insurance
Price range: $$

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Leased Property

How much square footage are you leasing?

What is the estimated replacement cost of ministry owned property?

Do you have a trailer or church-in-a-box?

Yes

What is the replacement cost of the trailer?

What is the replacement cost of the property inside the trailer?

Buildings and Property

Building Square Footage

Year Built

Number of Floors

Basement

Yes

Commercial Kitchen

Yes

Please provide year of last updates to the following:

HVAC

Electrical

Plumbing

Roof

What are the building's safety features?

(Check all that apply)

Fire Alarms

Central Station Alarms

Smoke Detectors - Hard Wired

Smoke Detectors - Battery Operated

Emergency Lighting

Sprinklers

Posted Evacuation Routes

Minimum 2 means of egress per building

Aside from your main location, does the ministry own or lease any other buildings or property?

Yes

Property #2

What is the address?

Street Address Address Line 2 City State ZIP Code

What best describes this property?

Other Property

Is this property owned or leased?

Owned

Leased

Building Square Footage

Year Built

Number of Floors

Basement

Yes

Commercial Kitchen

Yes

Please provide year of last updates to the following:

HVAC

Electrical

Plumbing

Roof

What are the building's safety features?

(Check all that apply)

Fire Alarms

Central Station Alarms

Smoke Detectors - Hard Wired

Smoke Detectors - Battery Operated

Emergency Lighting

Sprinklers

Posted Evacuation Routes

Minimum 2 means of egress per building

Does the ministry own or lease any other buildings or property?

Yes

Property #3

What is the address?

Street Address Address Line 2 City State ZIP Code

What best describes this property?

Other Property

Is this property owned or leased?

Owned

Leased

Building Square Footage

Year Built

Number of Floors

Basement

Yes

Commercial Kitchen

Yes

Please provide year of last updates to the following:

HVAC

Electrical

Plumbing

Roof

What are the building's safety features?

(Check all that apply)

Fire Alarms

Central Station Alarms

Smoke Detectors - Hard Wired

Smoke Detectors - Battery Operated

Emergency Lighting

Sprinklers

Posted Evacuation Routes

Minimum 2 means of egress per building

Does the ministry own or lease any other buildings or property?

Yes

Property #4

What is the address?

Street Address Address Line 2 City State ZIP Code

What best describes this property?

Other Property

Is this property owned or leased?

Owned

Leased

Building Square Footage

Year Built

Number of Floors

Basement

Yes

Commercial Kitchen

Yes

Please provide year of last updates to the following:

HVAC

Electrical

Plumbing

Roof

What are the building's safety features?

(Check all that apply)

Fire Alarms

Central Station Alarms

Smoke Detectors - Hard Wired

Smoke Detectors - Battery Operated

Emergency Lighting

Sprinklers

Posted Evacuation Routes

Minimum 2 means of egress per building

Does the ministry own or lease any other buildings or property?

Yes

Please list the address(s) of any other property owned by the ministry.

Building(s) Usage, Updates, & Significant Items

Are any building used for something other than what they were originally built for?

Yes

Are any buildings on a historical register?

Yes

Describe building(s) and appraisal

Do any buildings have aluminum wiring?

Yes

Has the building(s) been retrofitted by a licensed electrician?

Yes

Date wiring updated

Do any buildings have stained glass?

Yes

Value of stained glass

Please describe any religious artifacts or artwork (including stained glass) located inside or outside the premises if value is over $5,000

Is there an organ or other musical instrument?

Yes

What is the value and description of instrument(s)?

Do you lease any space to outside organizations?

Yes

Does lease contain an indemnification and hold harmless clause in favor of the ministry?

Yes

Do you obtain a Certificate of Insurance from lessee's policy?

Yes

Is sanctuary or any other house of worship building left unlocked when no staff is present?

Yes

Programs and Services

Do you have a youth group program?

Yes

Age range of children

Average weekly attendance

Youth group run by

Pastor(s)

Employee(s)

Volunteer(s)

Please describe your youth group activities

Are any minors in the ministry's care overnight?

Yes

Is a nursery available during worship activities?

Yes

Number of days per week nursery provided

Average number of children in nursery per week

Nursery staffed by

Employees

Volunteers

Are parents encouraged to visit the premises unannounced and observe children's activities?

Yes

Does your ministry operate any shelters?

Yes

Please describe each location and number of beds of each

How is the shelter staffed?

Employees

Volunteers

Hours shelter(s) are open

Please list any other community services provided by your ministry:

Do you have a security team?

Yes

Does your security team carry concealed weapons?

Yes

Are you planning any missions travel within the next 12 months?

Yes

Do you have any insurance in place for the trip(s)?

Yes

Please list countries and states visiting, length of stay, and number of people attending

Does the ministry sponsor any athletic leagues?

Yes

What are the sports played?

Number of Participants

Age of Participants

Do require all participants, or guardians, or sign a waiver of liability prior to participating?

Yes

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Does Applicant obtain on Accident and Health policy?

Yes

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What is the limit

Does the ministry use, or plan to use, swimming facilities?

Yes

The pool is

Owned and operated by the Applicant

Operated by other than the Applicant

Is at least one staff member certified in CPR present at swimming areas?

Yes

Pool Safety Features

(Check all that apply)

Lifeguards Present

Water Depths Marked

Pool Completely Fenced

Has Self-Locking Gate

Has a Diving Board

Has a Slide

Ratio of staff of child when at pools

Does the minsitry own or have access to a playground area?

Yes

Is playground fenced?

Yes

Are trampolines present?

Yes

Describe playground equipment and surfaces

Do any of the following apply?

Cemetery

Gymnasium

New Construction or Renovation

Skate Park

Counseling

What types of counseling performed by pastors or clergy?

(Check all that apply)

Alcohol

Marriage

Religious

Drugs

Pregnancy

Other

Other type of counseling

Have all pastors and clergy completed their degree at an accredited theological seminary?

Yes

Please describe training underwent

Does the ministry verify license, education, and other credentials for all counselors?

Yes

Is the ministry aware of any act, error, omission, fact, circumstance, or situation that might afford grounds for a future claim, suit, or action under professional liability?

Yes

Please describe in detail

Does the ministry use contracted counselors?

Yes

Are certificates of malpractice liability insurance obtained and maintained for all contracted counselors and health care providers?

Yes

Please indicate limit of liability

Is staff required to report all incidences that may result in a claim?

Yes

Is a written record kept?

Yes

Are procedures in place to protect confidentiality of clients?

Yes

Describe any closed-door counseling provided to individual clients

Have any past or present ministers, employees, or volunteers ever been accused, charged, or convicted, had a claim for damages submitted against, or sued in civil court for any type of sexual misconduct?

Yes

Identify the person(s), and submit a detailed account

Has the ministry ever had an incident which resulted in an allegation of sexual abuse?

Yes

Please describe

Was a claim made against the organization?

Yes

Please describe

Was a claim made against any employee(s)?

Yes

Please describe

Was the case settled?

Yes

Please describe

Does the ministry's current insurance program provide Abuse and Molestation coverage?

Yes

Current Abuse and Molestation Limit

It's ok to skip this question if you don't know.

Coverage Provided Is

It's ok to skip this question if you don't know.

Per Occurrence

Claims Made

Retroactive Date

It's ok to skip this question if you don't know.

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Does Applicant have current Professional Liability coverage?

Yes

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Limit of Liability

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Professional Liability is

Per Occurrence

Claims Made

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Retroactive Date

School Details

Type of School

Private School - Elementary

Private School - Secondary

College / University

Number of Students

Number of Teachers

Date School was Founded or Chartered

Describe security measures on campus

Does Applicant's school permit corporal punishment?

Yes

Does school have dormitories?

Yes

Dormitory number of buildings

Dormitory maximum number of stories

Dormitories Sprinklered?

Yes

Dormitories have hard-wired smoke detectors?

Yes

Dormitories have scheduled fire drills and testing?

Yes

Dormitories have emergency lighting?

Yes

Check any of the following allowed in dorm rooms

Incense Burners

Space Heaters

Hot Plates

Candles

Toasters or Toaster Ovens

Smoking

None

Any special classes provided?

Examples: Gymnastics, Dance, Karate, Tumbling, Horseback Riding, etc.

Yes

Describe special activities

Are any classes taught by independent contractors?

Yes

Where are classes taught by independent contractors?

On premises

Off premises

Does Applicant require a Certificate of Insurance from all sub-contractors?

Yes

Are waivers obtained by parents?

Yes

Does Applicant offer field trips?

Yes

What is the adult / child ratio on trips?

What is the minimum age of child?

Please describe field trips

Are instructors / coaches trained in physical education?

Yes

Is someone trained in first aid always present during practices or games?

Yes

Does Applicant have a Student Accident insurance policy

Yes

I Don't Know

Does school have any bleachers or grandstands on premises?

Yes

Type(s) of bleachers / grandstands

Indoor

Outdoor

Number of bleachers / grandstands

Age of bleachers / grandstands

Please check all types of sports played

Archery

Football

Soccer

Baseball

Golf

Softball

Basketball

Gymnastics

Swimming

Bungee Jumping

Ice Hockey

Tennis

Cheerleading

La Crosse

Trampoline

Climbing (Mountain, Rock, Wall)

Polo

Volleyball

Cross Country Track

Rugby

Water Skiing

Diving

Scuba Diving

Wrestling

Equestrian

Snow Skiing

Other

Field Hockey

Sky Diving

Other types of sports

Daycare Details

Based on the maximum number of children enrolled on the busiest day OR busiest season, enter the number of staff and children in each of the following age groups. (Do not duplicate before and after school children if they stay all day).

Infants, age 0-1: # of Children

Infants, age 0-1: Average Daily

Infants, age 0-1: # of Teachers

Toddlers, age 1-2: # of Children

Toddlers, age 1-2: Average Daily

Toddlers, age 1-2: # of Teachers

Toddlers, age 2-3: # of Children

Toddlers, age 2-3: Average Daily

Toddlers, age 2-3: # of Teachers

Preschool, age 3-5: # of Children

Preschool, age 3-5: Average Daily

Preschool, age 3-5: # of Teachers

School Age: # of Children

School Age: Average Daily

School Age: # of Teachers

Is anyone on staff under 18 years old?

Yes

Is a minimum of one staff member certified in first aid present at all times?

Yes

Is the Applicant's center exit directly to the outside?

Yes

To level ground?

Yes

Do the bathroom door lock?

Yes

Can bathroom doors be unlocked from the outside?

Yes

How often are evacuation drills performed?

Please describe Applicant's child release procedures

Does Applicant provide sick child, drop-in, latch-key, boarding, or camp services?

Yes

Please explain

Do any children require special care or treatment?

Yes

How many children require special care and treatment?

Please explain what special care or treatment is provided

Please indicate the following maintained on each child

(Check all that apply)

Immunization Records and Updated Annually

Signed releases from parents for emergency medical treatment / dispensing of medications

Written instructions from child's physician for dispensing child's medication

None of the above

Does Applicant have an Accident Insurance Policy?

Yes

I Don't Know

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Is coverage mandatory for all children?

Yes

Carrier Name

Limits

Policy Term

Vehicles and Transportation

Please list all vehicles used by the ministry

Year	Make	Model	Physical Damage	Actions

There are no Vehicles.

Maximum number of vehicles reached.

Do you require employees and volunteers to carry and show evidence of personal auto insurance?

Yes

Do you provide transportation services?

Yes

Do you have a formal driving policy in place?

Yes

Is driving policy communicated in writing to all employees and volunteers?

Yes

Is a signed acknowledgement form kept on file?

Yes

How often do you check MVR reports?

Please describe any ongoing training provided to drivers

Do employees or volunteers use their own vehicles for ministry purposes?

Yes

Please describe purpose

Do driving standards include the following?

(Check all that apply)

None

No major violations including DUI, racing, hit and run, speeding 20+ mph over

No more than 2 moving violations within the past 3 years

No more than 1 at-fault accident within the past 3 years

What is the procedure for dealing with driver accidents or violations?

How often are ministry vehicles inspected?

Never

Daily

Weekly

Monthly

Annually

No Vehicles

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Does Applicant utilize GPS fleet telematics devices?

Yes

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Fleet Telematics Utilized

Plug In

Hard Wired

Mobile Phone

Other

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Other Telematics

This field is hidden when viewing the form

Percentage of fleet provided with telematics devices

Staff and Volunteers

Please provide annual compensation amounts for each type of employee/sub contractor the ministry has.

Pastors & Clergy: # Full Time

Pastors & Clergy: # Part Time

Fee Based Counselors: # Full Time

Fee Based Counselors: # Part Time

Nurses: # Full Time

Nurses: # Part Time

Teachers: # Full Time

Teachers: # Part Time

Camp Counselors: # Full Time

Camp Counselors: # Part Time

Office Staff: # Full Time

Office Staff: # Part Time

Janitorial Staff: # Full Time

Janitorial Staff: # Part Time

Volunteers: # Full Time

Volunteers: # Part Time

# of Church Board Members

Workers Compensation

Please provide total annual compensation for each type of employee and subcontractor.

Pastors and Clergy

Please include housing allowance, if applicable.

Office Staff

Fee Based Counselors

Janitorial Staff

Teachers

Nurses

Camp Counselors

Does your employment process (for employees, contractors, volunteers, etc.) include verification if individual has ever been convicted of any crime, including sex-related or child abuse offenses before an offer is made?

Yes

Do you use an application for volunteers?

Yes

Does it include questions about whether the person has ever been convicted of any felony, including sex-related and/or child abuse related offenses?

Yes

Please describe in detail your screening process and guidelines for volunteers.

Do you conduct criminal background and reference checks for all employees?

Yes

Please explain

Do you conduct criminal background and reference checks for all volunteers?

Yes

Please explain

Do you conduct criminal background and reference checks for all independent contractors who interact or have access to children?

Yes

N/A

Please explain

Is there a new employee / volunteer orientation program that includes training in abuse awareness?

Yes

Do you require that no minor is ever alone with only one adult in any house of worship sponsored activity except in a counseling situation?

Yes

Ministry Financials

Total Assets

Current Fiscal Year

Previous Fiscal Year

Fund Balance

Current Fiscal Year

Previous Fiscal Year

Annual Revenue

Current Fiscal Year

Previous Fiscal Year

Please check any revenue sources that apply.

Donations

Retail or Product Sales (Ex. Coffee or Clothing)

Grants

What percentage of revenue is received online?

Are there any seasonal needs for increased money and securities limits?

Other than Christmas, Easter, or Mother's Day.

Yes

Dates Needed:

Limits Needed:

If volunteers are used to count / handle donations, please provide number used and screening required of same.

Has the ministry been the subject of, or involved in, any of the following in the past five (5) years?

Anti-trust, copyright or patent litigation

Disciplinary action by a regulatory agency

Action where a license was revoked or suspended

Administrative proceeding charging a violation of law

Any criminal actions

Please explain.

Has the ministry merged or anticipate merging with another organization?

Yes

Please explain.

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Additional Comments

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Leased Property

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Building(s) Usage, Updates, & Significant Items

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Counseling

School Details

Daycare Details

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Staff and Volunteers

Workers Compensation

Ministry Financials

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Leased Property

Buildings and Property

Property #2

Property #3

Property #4

Building(s) Usage, Updates, & Significant Items

Programs and Services

Counseling

School Details

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Vehicles and Transportation

Staff and Volunteers

Workers Compensation

Ministry Financials

Wrapping Up

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