Landmark Insurance Associates
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Church Questionnaire
Church Insurance Questionnaire
If you are human, leave this field blank.
Insured Contact info
This is the contact info we'll need for the primary individual insured.
Church Name
*
Church Website/Facebook
Physical Address
*
Your Name
*
Your Phone
*
Email
*
What kind insurance would you like us to quote?
Church
Auto
Work Comp
Umbrella
Other
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
Upload?
*
YES
NO - Complete questionnaire (10 minutes)
Church Section
Physical Address
*
Average Weekly Attendance
*
Current Insurance Provider & Renewal Date
Notes/Comments
Auto Section
Liability Limit
$500,000
$1,000,000
Other
Other
Medical Payments Limit
$5,000
$10,000
$15,000
$25,000
Any accidents in the last 3 years?
Yes
No
Not sure?
Not sure?
Notes/Comments
Driver Info
Please add additional drivers by using the "Add" button at the bottom. We need at least one driver to quote your coverage.
Driver's Name
Date of Birth
License Number#
Notes/Comments
Add another driver
Remove
Vehicle Info
Please add additional vehicles by using the "Add" button at the bottom.
Year
Make
Model
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?
Notes/Comments
Add another vehicle
Remove
Work Comp Section
Annual Payroll
Pastoral/Clarical Payroll
Pastoral/Clarical Payroll
Janitorial Payroll
Janitorial Payroll
Other
Other
Liability Limits
$500,000
$500,000
$1,000,000
$1,000,000
Other
Other
Notes/Comments
Umbrella Section
Umbrella Limit
$1,000,000
$2,000,000
$3,000,000
$4,000,000
$5,000,000
Other
Other
Notes/Comments
Other Insurance Coverage
Please provide information about the coverage you're looking for!
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