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Church & Charity Insurance

Name of Organization/Company:
Contact Name:
Address:
City:
Province:
Postal Code:	(X1Y 2Z3)
Phone Number:	(123-456-7890)
Fax Number:	(123-456-7890)
Email Address:	(xxx@yyyy.zzz)
Denominational Affiliation if Applicable:
Membership with Canadian Council of Christian Charities?	Yes    No
Current Policy Expiry Date:	(dd/mm/yyyy)
Age of building:	Less than 1 year 1 to 20 years 20 to 35 years More than 35 years
Construction of building:	Frame Masonry Non-Combustible Fire Resistive
Is the building sprinklered?	Yes    No
How much area do you occupy?	Less than 5,000 5,000 to 10,000 More than 10,000
Are you the only tenant?	Yes    No
Is there a hydrant within 500 ft. (150 metres)?	Yes    No
Is there a fire hall within 3 miles (5 kms)?	Yes    No
Has insurance ever been denied or canceled?	Yes    No
What type of operations?	Church Congregation Non-Profit Day Care! Nursery Christian School Bible College/Seminary Christian Campground Counselling Centre Drop-In Centre Missions Organization Evangelistic Ministry Denomination Office Other
How many years in the business?	Less than 1 years 1 to 5 years More than 5 years
Have there been any insurance claims in the last 3 years?	No <= 2 >= 3
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