SynagogueInsurance Quick Quote Form

1

Choose Coverage to Quick Quote!What type of coverage are you looking for?

Buildings/Business Property and Liability

Business Auto

Workers Compensation

Other

2

Your Name* This field is required.

First Name

Last Name

3

Your Contact Phone Number* This field is required.

4

Your E-mailPlease enter your full email address.

5

What state does your Organization reside in?Please select a state. If the state your organization resides in is not listed, please select "Other."

6

At this time, Quick Quote is not available in your state. However, we can still assist you in obtaining insurance quotes. Please complete the application, and we will be in touch with you shortly.

Press “Next” to continue.

7

Type of Organization* This field is required.What type of organization is seeking coverage?

8

"Other" Option:

At this time, Quick Quote is only available for Houses of Worship. However, we may still assist be able to assist you with obtaining insurance quotes. Please complete the application, and we will be in touch with you shortly.”

Press “Next” to continue.

9

At this time, Quick Quote is only available for Houses of Worship without preschool/K-12/Camp. However, we can still assist you in obtaining insurance quotes. Please complete the application, and we will be in touch with you shortly.

Press “Next” to continue.

10

Organization Name* This field is required.

Company Name

11

Website AddressThe web address of your organization

12

Organization's Address* This field is required.

Street Address

Street Address Line 2

City

State

Zip Code

Country

13

FEIN / Federal Tax ID* This field is required.

14

Average Weekly AttendanceThe web address of your organization

15

Name of Current Insurance ProviderPlease put N/A if you have none.

16

Number of Insurance Claims in the past 3 years?Please put N/A if you have none.

18

Building #1: Address, Year Built & Roof ReplacementPlease enter the address, year built, and the year of the last roof replacement. If it is the same as the original address please leave it as "Same as previously entered address."

Address 1

Year Built

Year of Last Roof Replacement

19

Building #2: Address, Year Built & Roof ReplacementPlease enter the address, year built, and the year of the last roof replacement. If it is the same as the original address please leave it as "Same as previously entered address."

Address 1

Year Built

Year of Last Roof Replacement

20

Building #3: Address, Year Built & Roof ReplacementPlease enter the address, year built, and the year of the last roof replacement. If it is the same as the original address please leave it as "Same as previously entered address."

Address 1

Year Built

Year of Last Roof Replacement

21

Building #4: Address, Year Built & Roof ReplacementPlease enter the address, year built, and the year of the last roof replacement. If it is the same as the original address please leave it as "Same as previously entered address."

Address 1

Year Built

Year of Last Roof Replacement

22

Building #5: Address, Year Built & Roof ReplacementPlease enter the address, year built, and the year of the last roof replacement. If it is the same as the original address please leave it as "Same as previously entered address."

Address 1

Year Built

Year of Last Roof Replacement

23

At this time, Quick Quote is only available for five buildings or fewer. However, we may still assist be able to assist you with obtaining insurance quotes. Please complete the application, and we will be in touch with you shortly.”

Press “Next” to continue.

24

Please enter the address, year built, and date of the most recent roof replacements of every building you want to be included in the quote.Please enter a new line for each building.

25

Do you own or operate a cemetery at a separate location?

YESNO

26

Please check if you:Check all that apply.

27

Appraised replacement value of your Torah(s): Enter $0 if none or not known

28

Do you own a Parsonage?

YESNO

29

Have any of your organization's past or present employees, volunteers, or representatives ever received a report, a complaint, an allegation, ever been charged, convicted, had a claim for damages submitted against, or sued in civil court for any type of sexual misconduct?

YESNO

30

Is there a formal safety or security program in operation?If no, that’s Ok – we can help!

YESNO

31

Does your current policy include Directors & Officers Liability and or Employment Practices Liability?

YESNO

32

Do you want a quote for Cyber Risk?

YESNO

33

Number of paid staff

34

Annual Payroll of Clergy and Church Professionals (ex: Administration, Sunday School Teachers, Musicians)The total dollar value.

35

Annual Payroll of Maintenance Staff/Landscapers (including 1099’s)The total dollar value.

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Vehicle #1 Information Please enter the year, make model, number of seats, VIN, and use of the vehicle below.

Year

Make & Model

Number of Seats

VIN #

Vehicle Use

38

Vehicle #2 Information Please enter the year, make model, number of seats, VIN, and use of the vehicle below.

Year

Make & Model

Number of Seats

VIN #

Vehicle Use

39

Vehicle #3 Information Please enter the year, make model, number of seats, VIN, and use of the vehicle below.

Year

Make & Model

Number of Seats

VIN #

Vehicle Use

40

Vehicle #4 Information Please enter the year, make model, number of seats, VIN, and use of the vehicle below.

Year

Make & Model

Number of Seats

VIN #

Vehicle Use

41

Vehicle #5 Information Please enter the year, make model, number of seats, VIN, and use of the vehicle below.

Year

Make & Model

Number of Seats

VIN #

Vehicle Use

42

Please enter the year, make, model, and VIN number for every vehicle you want to be included in the quote.Please enter a new line for each vehicle.

43

Quick Quote Form is Complete!