Landmark Insurance Associates
Resisting Evil Workshop
Church Insurance Questionnaire
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Insured Contact info
This is the contact info we'll need for the primary individual insured.
What kind insurance would you like us to quote?
Would you like to upload a copy of your current coverage?
You're welcome to upload a copy of any coverage you would like us to quote or you can complete our questionnaire. The questionnaire can take 10-20 minutes to complete depending on how much info you have to input. You can also call us and we'll fill this out over the phone with you. (877) 747-1982
NO - Complete questionnaire (10 minutes)
Average Weekly Attendance
Current Insurance Provider & Renewal Date
Medical Payments Limit
Any accidents in the last 3 years?
Please add additional drivers by using the "Add" button at the bottom. We need at least one driver to quote your coverage.
Date of Birth
Add another driver
Please add additional vehicles by using the "Add" button at the bottom.
VIN (Vehicle Identification Number)
Check all that apply
Do you want Comprehencive or Collision Coverage?
Vehicle have anti-theft device?
Is vehicle used for delivery?
Add another vehicle
Work Comp Section
Other Insurance Coverage
Please provide information about the coverage you're looking for!