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Church Information
Business Name
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First Name
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Last Name
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Church Address
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City
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State
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ZIP / Postal Code
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Fax Number
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E-Mail Address
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Year Built
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Number of Buildings
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Combined Square Footage
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Number of Stories
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Construction Type
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Roof Type
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Number of Playgrounds or Sports Fields
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Annual Payroll
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Coverage Information
New Policy Start
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/ /
New Policy Term
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Prior Policy Expiration
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Prior/Current Policy Carrier
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Current Policy Premium $
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Building Coverage
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Contents Coverage
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Instruments Coverage
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Occurances Coverage
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Describe any additional coverages needed
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Losses/Claim
Number of Claims in the past 3 years
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Additional Information
Agent Name (Optional)
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How Did You Hear About Us ?
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Preferred Contact Method
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Additional Comments
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Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

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1802 S Parrott Ave
Okeechobee, FL 34974
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