AGENT Volunteer Church Security GROUP QUESTIONNAIRE

Volunteer Church Security GROUP QUESTIONNAIRE
GENERAL INFORMATION
Church Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact Name
E-Mail
example@example.com
Telephone
Format: (000) 000-0000.
Fax
Format: (000) 000-0000.
Does the Church hold services at any other location?
If “Yes”, provide addresses below.
INFORMATION ABOUT THE CHURCH
Denomination:
How many members are in the Congregation?

How often are services held? Note time slots in the chart provided below.

Rows	Time	Time	Time	Time	Time
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday

Does the Church have General Liability insurance in place?
If “Yes”, provide the following:
CARRIER NAME
LIMIT
DEDUCTIBLE
EFFECTIVE DATE

MonthDayYear
Date
Has the Church had any liability losses in the past five years?
If “Yes”, provide details below.
INFORMATION ABOUT THE VOLUNTEER SECURITY TEAM
What is the total number of the volunteer Church security team members?
How many volunteers are assigned to each Church service?
How are potential volunteers recruited?
Do security team members carry firearms during Church Services?
If “Yes” does the Church confirm members are legally authorized to possess/carry a firearm?
Are background checks done on all security team members?
Are security team members required to (select all that apply):
Does the Church have a committee dedicated to security matters?
If "Yes":
Do any members have law enforcement or military experience?
Were the committee’s security plans developed with assistance from qualified outside vendors (Serving Watchmen, Sheep Dogs, Strategos, etc)?
THE APPLICANT WARRANTS THAT THE STATEMENTS AND RESPONSES TO THE QUESTIONS ON THIS APPLICATION ARE TRUE AND COMPLETE.
THIS APPLICATION DOES NOT BIND THE APPLICANT OR THE COMPANY, NOR DOES IT OBLIGATE THE COMPANY TO ISSUE A POLICY. SUCH POLICY MAY BE CANCELLED BY THE COMPANY FROM INCEPTION UPON DISCOVERY THAT THE POLICY WAS OBTAINED THROUGH A FRAUDULENT STATEMENT, OMISSION, OR CONCEALMENT OF THE FACTS MATERIAL TO THE ACCEPTANCE OF THE RISK OR HAZARD ASSUMED.
Signature
Date

MonthDayYear
Date
Volunteer Church Security Roster
(*) QUALIFIER LEGEND

A – Current/former law enforcement officer
B – Current/former member of military
C – Prior security service experience
D – Successfully completed security training
E – Other (additional detail required)

Note: Name, Qualifier, and Armed (Y/N) are required

Rows	Name	Address	City/State/Zip	E-Mail	Qualifier*	Armed (Y/N)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25

TO BE COMPLETED BY INSURANCE AGENT:
Agent Name:
E-Mail
example@example.com
Fax
Telephone
Please enter a valid phone number.Format: (000) 000-0000.
Agency Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Should be Empty:

Volunteer Church Security GROUP QUESTIONNAIRE

GENERAL INFORMATION

INFORMATION ABOUT THE CHURCH

INFORMATION ABOUT THE VOLUNTEER SECURITY TEAM

Volunteer Church Security Roster

TO BE COMPLETED BY INSURANCE AGENT: