Church Intake Form - Hale Street Insurance
Please complete this form to help us understand your needs and assess any relevant risks.
Organization
Legal name of organization
Federal EIN (FEIN)
*
Physical address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary contact
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Congregation and Operations
Average weekly worship service attendance
Total number of members / parishioners
Number of volunteers
Total number of employees (full and part time)
Total annual payroll
Annual operating budget
List all community services provdied
Food pantry
ESL classes
Counseling
After-school programs
Homeless shelter
Addiction recovery
Prison ministry
Does the organization lease premises to outside groups
Yes
No
Does the organization have foreign travel exposure in the next 12 months?
Yes
No
Physical Properties and Buildings
Complete for each building
How many buildings do you own or lease?
1
2
Other (for 3+ buildings proceed with form and we will contact you)
Building address
Building 2 address
Building occupancy / primary use
Sanctuary
Education
Office
Parsonage
Clergy housing
Fellowship hall
Multi-use
Building 2 occupancy / primary use
Sanctuary
Education
Office
Parsonage
Clergy housing
Fellowship hall
Multi-use
Construction type
Masonry
Frame
Masonry non-combusitble
Jointed masonry
Steel frame
Mixed
Building 2 construction type
Masonry
Frame
Masonry non-combusitble
Jointed masonry
Steel frame
Mixed
Total square footage
Building 2 total square footage
Number of stories
Building 2 number of stories
Is the building on a historical register?
Yes
No
Building 2: Is the building on a historical register?
Yes
No
Is the building over 100 years old?
Yes
No
Building 2: Is the building over 100 years old?
Yes
No
Year of last roof replacement or repair
Building 2: Year of last roof replacement or repair
Type of roof (check all that apply)
Slate
Asphalt shingle
Flat / rubber / membrane
Metal
Wood shingle
Tile
Building 2 type of roof (check all that apply)
Slate
Asphalt shingle
Flat / rubber / membrane
Metal
Wood shingle
Tile
Type of foundation
Masonry
Brick
Concrete
Wood
Mixed
Building 2 type of foundation
Masonry
Brick
Concrete
Wood
Mixed
Primary heating source
Forced air (oil / gas)
Boiler / steam
Electric baseboard
Wood burning
Heat pump
None
Building 2 primary heating source
Forced air (oil / gas)
Boiler / steam
Electric baseboard
Wood burning
Heat pump
None
Plumbing and Electrical
Year electrical was last updated
Building 2: Year electrical was last updated
Is there any knob and tube wiring present?
Yes
No
Building 2: Is there any knob and tube wiring present?
Yes
No
Is there any aluminum wiring present?
Yes
No
Building 2: Is there any aluminum wiring present?
Yes
No
Type of electrical panel
Circuit breaker
Fuse box
Building 2 type of electrical panel
Circuit breaker
Fuse box
Year plumbing was last updated
Building 2: Year plumbing was last updated
Primary plumbing type (check all that apply)
Copper
Brass
Galvanized steel
PVC / plastic
Mixed
Building 2 primary plumbing type (check all that apply)
Copper
Brass
Galvanized steel
PVC / plastic
Mixed
Fire and Life Safety
Does every building have a functioning fire alarm system?
Yes
No
Does every building have smoke detectors?
Yes
No
Does every building have emergency lighting?
Yes
No
Does every building have sprinkler system?
Yes
No
Staffing and Volunteers
Enter number of employees, volunteers, and contractors in each category
Staff count
Rows
Employees
Volunteers
Contractors
Pastors / ministers / clergy
Administrators
Clerical staff
Teachers and daycare workers
Counselors
Health care professionals
Mental health professionals
Security personnel
Maintenance staff
Counseling and Professional Services
What kind of counseling does the organization provide? (select all that apply)
Marriage / family
Religious / pastoral
Alcohol / substance abuse
Drug treatment
Pregnancy
Mental health
None
Does the organization verify licenses and credentials for all counselors?
Yes
No
Have all clergy completed degrees at accredited theological seminaries?
Yes
No
Is staff required to report all incidents that may result in a claim?
Yes
No
Children and Youth Programs
Is a nursery available during worship services?
Yes
No
Is a youth group program offered?
Yes
No
Does the organization operate a daycare or preschool?
Yes
No
Does the organization operate a school?
Yes
No
Abuse and Molestation Screening
Does the employment process include criminal background checks for employees, volunteers, and contractors?
Yes
No
Does the organization use written applications for volunteers?
Yes
No
Are personal interviews conducted for all employees and volunteers?
Yes
No
Are personal references checked?
Yes
No
Is at least 5 years of employment history verified?
Yes
No
Has the organization ever had an incident resulting in an allegation of sexual abuse?
Yes
No
Does the organization's current insurance program provide abuse and molestation coverage?
Yes
No
Security
What security measures are in place?
Electronic locks
Alarmed doors
Security cameras
Unarmed security gaurds
Armed security gaurds
Visitor sign-in
Keypad entry
Written security handbook
Security training program
Criminal background checks for all security personnel
Vehicles and Transportation
Does the organization lease or own any vehicles?
Yes
No
Estimated total yearly mileage across all owned / leased vehicles
Special Events and Fundraising
Does the organization hold special events or fundraisers?
Yes
No
Does any event have attendance over 500?
Yes
No
Does any event involve alcohol? (do not answer yes if only for communion)
Yes
No
Special Property
Does the building have stained glass?
Yes
No
Does the organization have an organ or other significant musical instrument?
Yes
No
Does the organization have any artifacts or artwork valued over $5000?
Yes
No
Finance and Legal Profile
Total assets of the organization
Total annual revenue or donations
Has the organization had any insurance claims or losses in the past 3 years?
Yes
No
Submit
Should be Empty: