Church Insurance Quote

First & Last Name:  
Street Address:  
City, State & Zip:  
E-Mail Address:  
Telephone:  
Fax:  

Current Insurance Information
Insurance Company Name:  
Policy Exp. Date:  
Amount Insured for:  
Mortgage Amt:  
Premium Amt:  
Term:  
Any Claims in Last 3 years?  
# of floors:  
Construction:  
Roof type:
Age of roof:
Age of Church:
Full Baths:
1/2 Baths:
Sq. footage:  
# of Buildings:  
Annual Church Payroll:
# of Playgrounds/Sports Fields:

Coverages:
Building:
Contents:
Instruments:
Occurances:
Please list any other coverages you may need:

Give any additional information that may assist us in providing you with an accurate church insurance quote:
Note: By submitting this form you understand that no coverage is bound unitl you receive written notice.



©2005 Copyright Dimond Bros. Agency, Inc. All Rights Reserved  
Headquarters: 111 Sheriff St., P.O. Box 1090, Paris, IL 61944 217-465-5041 voice / 217-463-3809 fax