<p> www.methodistone.com</p><p>1-800-364-3122, ex. 231, Direct 713-974-6865, Fax 713-974-0133 / Email: [email protected]</p><p>Name of Church______</p><p>Mailing Address______County______</p><p>Street Address______</p><p>City______State______Zip______</p><p>Number of Members/Participants ______Parent Organization ______</p><p>Year Established ______Federal Employers ID Number ______</p><p>Contact Name ______Phone Number ______</p><p>Email ______Website ______</p><p>Additional Names (DBA’s, Foundations, Etc) ______</p><p>______</p><p>Financial Information: Please provide details if any deficit exists including cause and how it will be eliminated: </p><p>Budget Year Total Assets Revenues Expenditures Surplus (+) Deficit (-) Current year Prior Year Previous year</p><p>Current Insurance Effective Date Insurance Carrier Expiring Premium</p><p>Property & Liability Package ______</p><p>Automobile Liability Insurance ______</p><p>Workers’ Compensation ______</p><p>Directors & Officers Liability ______</p><p>Employment Practices Liability ______</p><p>Umbrella (Excess Liability) ______</p><p>Other ______PROPERTY</p><p>Property Yr. Sq Constructio Building Content Burglar Sprinkle Smoke # of Electrical Plumbin Roof Flood Built Foot n type Value s Value y Alarm r Y/N Alarm Storie Updated g Updated Zone/EQ Y/N Y/N s (Year) Updated (Year) Zone (Year)</p><p> address</p><p> address</p><p> address</p><p> address</p><p> address</p><p> address</p><p> address</p><p>NOTE: Contents does not include the pastor’s personal belongings. The pastor should purchase a renters insurance policy to cover their personal liability and belongings. </p><p>Date of Most Recent Appraisal: ______PROPERTY Continued</p><p>Indicate if you have established procedures to adequately control premises condition in the following areas: Written program of facility and equipment inspections Yes No If yes, frequency of inspections Preventive Maintenance Program of electrical & heating equipment, roofs, and plumbing. Yes No Does the facility have Commercial Cooking equipment Yes No If yes, please advise if equipment protected by: Automatic fire suppression systems (UL300) Yes No Standard ventilation hood and ductwork Yes No </p><p>Are any of your buildings on the historical registry? _____ </p><p>Do your buildings have unique or irreplaceable building characteristics (Tiffany stained glass) ? _____</p><p>If buildings are equipped with fire and burglar alarms, are they:</p><p>Yes Central Local No </p><p>If “yes” which locations?______</p><p>. Lightening Protection? Lightning rod exists, is grounded? Yes No N/A </p><p>Steam Boiler Explosion: Description of Equipment:______</p><p>Certificate Number:______Certificate expiration date:______</p><p>Do you own a cemetery?______Number of Acres?______</p><p>Vacant Land?______Number of Acres?______</p><p>Are any buildings listed under construction or is any construction planned within the next 12 months? </p><p>Yes No If “yes” a Construction Questionnaire will need to be completed.</p><p>3 LIABILITY</p><p>Please indicate any of the following operations &/or activities you currently have: Maintain cemetery Firework displays Health facility or medical programs offered Swimming Pool(s) Events with liquor sales Homeless shelter or emergency housing Sponsored athletic teams Meal programs Rape, suicide, abuse, other crisis center Cell phone or radio tower Owned camps Orphanage or child placement service In Home Services Overseas Missionary work or trips Health & fitness facility</p><p>Please indicate any of the child care services provided for your members: Nursery school during services only Mothers Day out services Before &/or after care school services Full time Day Care operation (if yes complete Day Care section) Adult day care services</p><p>Please provide details of operations for each activity indicated above: </p><p>Do you operate or sponsor any sports teams? Yes No If yes, describe all sports offered: Do you require a permission/release form for participants under age 18? Yes No </p><p>Do you offer a Youth Group program? Yes No Age range of children: Number of attendance each week: Please indicate what operational procedures you have implemented for all youth sponsored activities: Required signed parent permission slip Have signed injury waiver signed by parent/guardian Verify adequate supervision with proper adult to youth based on age/activity Does any of your youth activities involve climbing, skiing, rafting, ropes, horseback, snowmobiles, or survival training. Yes No </p><p>OWNERSHIP/OPERATIONS:</p><p>Thrift Store Yes No If yes, what are your annual sales?______</p><p>Soup Kitchen Yes No If yes, how many meals? ______</p><p>Meals on Wheels Yes No If yes, # of participants? ______</p><p>Camp Yes No If yes, # of campers? ______</p><p>Rental Property Yes No If yes, attach property details.</p><p>Employees, Church Members or others who travel overseas on church business: Yes No</p><p>Broadcasting Yes No </p><p>Alternative to prison programs? Yes No </p><p>4 DIRECTORS, OFFICERS & ORGANIZATION LIABILITY </p><p>Retro Date: </p><p>Within the past five years, has any claim been made or has notice been given under any of the previous coverage Yes No If yes please provide details: </p><p>Is any Insured aware of any fact, circumstance or situation involving any Insureds that might reasonably be expected to result in a claim? Yes No If yes, please provide details: </p><p>Any changes, expansion or consolidation planned in the operations of the religious institution over the next 18 months? Yes No If yes, please provide details: </p><p>COUNSELING PROFESSIONAL LIABILITY </p><p>Please provide employee count by position: </p><p>Position # full time # part time Position # full time # part time Administrators Clerical Clergy Teachers Counselors Nurses Camp Volunteers Counselors Other Total Leased Temporary Contractor Employees </p><p>List any certification and certifying organization (i.e. certified counselor, ordained minister, etc.): Please advise type of counseling offered by your clergy? Religious Marriage Family Drugs-Alcohol Pregnancy Other please provide full details Please provide any specialized training and certification of counselors: Have all clergy completed their degree at theological seminary or ordained? Yes No Do you verify license, education and other credentials for all counselors? Yes No Are clients referred to specialists when appropriate? Yes No Any past or pending claims or suits against you on account of any alleged malpractice, error or mistake? Yes No If yes, please provide details: </p><p>5 DAYCARE / NURSERY / PRE-SCHOOL / BEFORE - AFTER CARE / K - 12 Specify the applicable number for each age group # Children # Adults # Children # Adults Infants (0-24mos) Toddlers (25-36mos) 3 year olds 4-5 year olds Is the day care currently licensed by the state? Yes No Has the license ever been revoked Yes No</p><p>Is there a written drop-off and pick-up procedure Yes No Is corporal punishment practiced Yes No If yes, attach written procedures Employee Information: Number of staff members Describe the educational background of the Director: Are staff members trained in first aid including cardiopulmonary resuscitation Yes No Do employees dispense medicine Yes No If yes, are prescription labels or instructions from parent required Yes No Type of School Hours of operation Grades to TOTAL number of students enrolled </p><p>Is the school licensed? Yes No</p><p>ATHLECTICS</p><p>Please check all sports played and indicate whether they are interscholastic (o) or Intramural (I) Archery Baseball Basketball Cheerleading Climbing Cross Country Track Equestrian Field Hockey Football Golf Gymnastic Ice Hockey La Crosse Polo Rugby Soccer Softball Swimming Tennis Wrestling </p><p>Does your school have bleachers? Yes No If yes, what type? ______</p><p>MEDICAL</p><p>Do you have medical facility/infirmary? Yes No</p><p>Does the facility dispense medication? Yes No</p><p>Does the facility provide first aid? Yes No</p><p>Are written instructions from parents required before dispensing medicine? Yes No</p><p>6 SEXUAL MISCONDUCT LIABILITY </p><p>Have you ever had a claim involving abuse (physical or sexual) or sexual molestation? Yes No Are you aware of any situation which may present a claim in the future? Yes No If yes, please provide details, including final resolution: </p><p>Do your employment applications for both staff and volunteers include questions pertaining to prior convictions for any crime, including sex-related or child-abuse related offenses? Yes No Is documentation of employment applications and background/reference checks maintained? Yes No</p><p>Do you have a written policy(s) designed to prevent abuse, molestation, and sexual harassment? Yes No a. If “Yes”, are these policies and guidelines communicated to all employees and volunteers? Yes No b. Is documentation of the communication of your policies prohibiting abuse maintained? Yes No c. Are criminal background checks performed on all children and youth volunteer positions? Yes No</p><p>Do you discuss the following items at staff orientation: d. Child / sexual abuse? Yes No e. How to recognize the signs? Yes No f. What to do if a member / child report someone molested him/her? Yes No</p><p>Please indicated all additional administrative practices you have implemented to prevent abuse situations: We have a waiting period before a new member/volunteer can work with children or youth programs We limit volunteers and staff from being alone with any child (requiring more than one adult at all times) We utilize a “volunteer application” and require them to complete orientation training with regard to our abuse policy All staff and volunteers are required to sign an acknowledgement of receipt and understanding of our abuse policy We encourage and allow parents to visit their child at any time unannounced to observe children’s activities We have appointed a coordinator to review and investigate any allegation of an abusive or harassment situation Our sexual abuse policy contains the required reporting and investigation procedures for employees and volunteers </p><p>CRIME PROTECTION: </p><p>Yes No Are collections left overnight in the church? </p><p>Is there a safe on the premises? If yes, please describe______</p><p>Is countersignature required on checks?</p><p>Frequency of cash / accounts audits and by whom?______</p><p>Number of employees______</p><p>7 How many employees or volunteers handle money?______</p><p>8 AUTO</p><p># of Year Make Model VIN Cost new Garaged Passengers</p><p>Does the church have a vehicle maintenance program in place? Yes No Does the church have a driver training program in place? Yes No Are all vehicles stored/parked at a locked location? Yes No Are proper restraints available for all passengers? Yes No Are employees/volunteers required to show proof of personal insurance? Yes / No</p><p>Attach a list of all drivers (Name, driver’s license number, date of birth & state)</p><p>Are any vehicles rented or loaned to others or used by outside groups? Yes No If yes please advise the following: Maximum Radius of trip Loaned with employed driver Yes No Verify the driver has proper license for unit (CDL) Yes No</p><p>Do you own or operate any 15 passenger vans? Yes No If yes please answer the additional questions below. Are vehicles equipped with Electronic Stability Control (ESC) Yes No Do you limit number of occupants to <10? Yes No Do you complete pre-trip inspection? Yes No Do you use designated experienced driver(s) for the vans? Yes No Have you remove back-seat Yes No</p><p>Do you provide transportation service for physically handicapped passengers? Yes No If yes please advise: Do vehicles equipped for wheelchairs have tie-down belts to stabilize the wheelchair- passengers? Yes No </p><p>Note: Drive other Car Coverage: If a Pastor or a Church official does not have a personal car or personal automobile insurance, you may want to purchase this coverage to protect the Pastor, other Church officials and their spouse while using the automobile. If so, please provide a list including the names and driver’s license numbers of those individuals. Add note requesting Driver other Car Coverage at top of list. </p><p>9 LOSSES:</p><p>Please list all losses for all lines of coverage incurred during the last 4 years and attach insurance carrier loss runs for that period of time. Please check here if your church has had no known losses </p><p>Date Nature of Loss Amount of Loss</p><p>______</p><p>______</p><p>______</p><p>Signed By:______Date Submitted:______Phone:______</p><p>Print Name:______Home Phone:______</p><p>10</p>