State Farm Fire and Casualty Company Agent's Name

Home Office, Bloomington, IL 61710 XXX XXX XX

Agent's Code
XX-XXXX
Commercial Multi-Peril Application Religious Organization Policy Number

New Rew of Policy Number Effective Date Expiration Date Existing Yes No
Inquiry Only State Farm® Client

Applicant
Last Name First Name Middle Name or Initial
XXXX XXXX
Date of birth - for individual only

The named applicant is Partnership

Email Website
Address XXX@XXX.XXX Address XXX.XXX.XXX

Home Phone (999) 999-9999 ext. 99999 Work Phone 9999999999 ext. 99999

Cell Phone 9999999999 ext. 99999 Fax Number 9999999999 ext. 99999
Number and Street City State ZIP Code
Mailing
Address XXXX XXXX XX XXXX WI XXXXX-XXXX
Name and address
of management firm / trustee XXXX

Person to contact Contact's

for inspection XXXX phone number 9999999999 ext. 99999
Applicant(s) Acknowledgement
Coverage is not provided until this application is approved by the State Farm Underwriting Department.
By submission of this application, you agree that: (1) You have read this application, (2) your statements on this
application are correct, (3) the minimum policy limits are in force, (4) all vehicles are insured, (5) the premium charged
must comply with State Farm's rules and rates and may be revised, and (6) traffic violation reports may be obtained by
the company named hereon on any person named as a driver of the insured motor vehicle at any time.

REGARDING CONSUMER REPORTS...

Consumer reports may be ordered in conjunction with this application. These reports provide information that assists with determining your eligibility
for insurance.

Other Interests
Type: Named Additional Insured
If Named Additional Insured, explain:
XXX

Name

XXX
Number and Street

XXX XX
City State ZIP Code Loan Number Mortgagee Subset Code

XX IA 99999 99
EA 2532 WI.1 Rev. 07-2022 Page 1 of 8 1007265 2014 148494 214 05-09-2023
Does the Additional Interest need to receive a copy Yes No Note: If Additional Interest requires a Certificate of Insurance, please attach a copy of
of the policy declarations at issuance and renewal? the issued ACORD® Certificate of Insurance to the application when submitted.
Yes No
Does the Additional Interest need to receive a copy of the cancellation notice?

General Information
Yes No
Does this risk meet all Underwriting Guide Requirements?
Yes No
Has any insurer canceled or refused to issue or renew similar insurance for the named applicant within the past 3 years?
If yes, please provide an explanation:
XXX

Yes No
Has the applicant been insured with State Farm under a Commercial Package policy within the last 3 years?
If yes, please list policy numbers:
999999999

Yes No
Has the applicant had business insurance for the last 3 years?
If yes, complete the following:
Current and prior insurance carrier(s) Policy number Insured from To

XXXX 999999999 XX/XX/XXXX XX/XX/XXXX

Yes No
Has applicant had a loss, insured or not, in the past 3 years (fire, wind, crime, liability, etc.)?
If yes, please list losses below:
Date of Loss Cause and Description of Loss Total Amount of Loss

XX/XX/XXXX XXXX $ 9,999

Religious Organization Worksheet

Please complete an Additional Building / Location Supplemental page for each additional building / location.

Location Schedule
Coverage A - Building(s) Coverage B - Business Personal Property

CMP - Replacement Cost Replacement Cost

Yes No
If more than one building/location: Schedule Exclude Theft coverage?

Additional scheduled buildings or locations

Location Number Building Number Location of Property - Number and Street
999 999 XXXX XXXX XX
City State ZIP Code County

XXXX XX XXXXX-XXXX XXX

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Coverage A - Building(s) Coverage B - Business Personal Property
Submit replacement cost estimate / documentation for each building type. Include values of leased furniture and equipment. Include the value of
improvements and betterments if the applicant is a tenant.
Building $ 9,999 Contents (including average inventory) $ 99
Auxiliary Structures - (Includes value of all outbuildings, fences,
walkways, and lights. Note types of structures below.)
Property of Others $ 99
Tenant's Improvements and Betterments $ 99
Auxiliary Structures $ 9,999 Owned and Leased Furniture $ 99
Describe XXXX
Owned and Leased Equipment $ 99
Total Business Personal Property $ 495
Xactware estimate reference number 999

Applicant's interest in the premises: Owner-occupant

Yes No
Is any portion of an Owner-Occupied building or Condominium Unit leased to others?

If yes, provide explanation and

square footage in the space provided. XXXX

Total square footage of area (Owner-lessor and condo unitowner risks only) square feet Year built XXXX
Average weekly attendance for this location In what year was the
(how many people, on average, attend services on a weekly basis?) 99 Stat Class 999 congregation formed? XXXX
Yes No
Are there any residential units at this location? If yes, number of units? 99 How long at this location? 9 years

Construction: Frame

List age of the following: Heating Plant 9 years Wiring 9 years Plumbing 9 years Roof 9 years

Roof Material: Comp shingle

Auxiliary structure building construction: Frame

Zone 9 Subzone 9 Protection Class (not applicable in all states) 999

Name of Fire Protection Area (FPA) where
risk is located (as listed in the Rate) XXX
Distance to Is risk Yes No If no,
servicing fire station 9 miles inside city limits? explain: XXX
Is risk located within Yes No Is Risk 100% fully protected Yes No Is sprinkler system Yes No
1,000 feet of hydrant? with an automatic sprinkler system? inspected annually?

Number of stories 9 Number of fire divisions 9 Number of units per fire division 9
Protective Devices - Local pull station Fire or smoke Central station / proprietary
check all that apply: Local burglar alarm
fire alarm central station alarm burglar alarm
Name of
alarm company XXX Certificate number 999
Description
of system XXX
List all occupancies /
exposures within 60 feet XXX
PERIL BASED RISK INFORMATION:
Yes No
According to the Peril Based Risk Information System (PBRI), is the risk located within any defined PERIL BASED EXPOSURE AREA?
Check all that may apply:
Wind Hail Earthquake Hurricane Surge Wildfire / Firebreak+ Landslide Other defined setback area

EA 2532 WI.1 Rev. 07-2022 Page 3 of 8 1007265 2014 148494 214 05-09-2023
If other, explain:
XXX

Premises
inspected by XXX Title XXX Inspection date XX/XX/XXXX
Additional Coverages

Deductible $ 9,999
Coverage L - Liability

Occurrence Limit $ 99,999

Note: The annual aggregate and Products / Completed Operations aggregate limits are equal to 2 times the Occurrence limit.

Coverage M - Medical Payments

$5,000 Each Person - Included Other $ 9,999

Note: Subject to the occurrence and annual aggregate limits.

Extensions and Endorsements (check boxes - can select multiple) - *see BPC Summary for amounts included
Property
Amount Included Additional Elected
Property Selection (if any) Amount Total Coverage

On premises $10,000 + $999 = $10,999

Accounts Receivable
Off premises $5,000 + $999 = $5,999
Back-Up of Sewer or Percent of contents
Drain (contents only) below grade
99 % $15,000 + $999 = $15,999

Property $25,000 + $999 = $25,999

Computer Property Form
Loss of income and
extra expense
$0 + $999 = $999
Deductible: $500

Condominium Loss Assessment (Unitowners only) $1,000 + $999 = $1,999

Is a master policy in Yes No
force for the building? Insurance Carrier XXX Policy number 99999999
Data Compromise (Identity Restoration must also be selected)

Earthquake EQ Zone 9 Earthquake deductible 99 %

Yes No
Is there evidence of unrepaired prior damage OR unusual settling, cracking or deterioration of masonry foundations or walls?
If yes, explain:
XXX

Yes No
Is the foundation wall solid brick or stone?
Yes No
Is the structure built in whole or in part on piers, pilings, stilts or not resting completely on solid ground?
Yes No
Is the structure located on a steep slope (greater than 30 degrees) or within 50 feet of the top or bottom of a cliff?

EA 2532 WI.1 Rev. 07-2022 Page 4 of 8 1007265 2014 148494 214 05-09-2023
 Amount Included Additional Elected
Property Selection (if any) Amount Total Coverage
Employee Number of employees
Dishonesty 99 $25,000 + $999 = $25,999
(for all locations)

Equipment Breakdown (included)

Identity Restoration

Loss of Income and Extra Expense (not included)

Loss of Income (not exceeding 12 consecutive months) - actual loss sustained: $ 999
Estimated annual gross receipts / sales: $ 999
Mine Subsidence Coverage (Not available in all counties)

Building

Auxiliary Structure(s) - if applicable

Rejection of Mine Subsidence Coverage - Applicable only for those counties with mandated Mine Subsidence Coverage.
Refer to the Illinois Underwriting Guidelines for a listing of the applicable counties. The applicant must complete the Mine Subsidence Rejection
Form and submit it with this application.
Amount Included Additional Elected
Property Selection (if any) Amount Total Coverage

Money and Securities (special deductible of $100 applies) $5,000 + $999 = $5,999
Does applicant Yes No What Max cash Are checks stamped Yes No
have a safe? type? XXX on hand? $999 "for deposit only"?
Amount Included Additional Elected
Property Selection (if any) Amount Total Coverage

Personal Property Off Premises $15,000 + $999 = $15,999

Property of Others $2,500 + $999 = $3,499
Ordinance or Law
Select one or both of the following: Increased Cost of Construction and / or Demolition 25%
Ordinance or Law
22 Loss of Value to the Undamaged Portion of Building
Increased Cost or Loss of Value
Amount Included Additional Elected
Property Selection (if any) Amount Total Coverage

Outdoor Property $5,000 + $999 = $5,999

On premises $10,000 + $999 = $10,999
Valuable Papers
Off premises $5,000 + $999 = $5,999

Other XXX

Liability
Property Damage Deductible Amount $ 999
(Please complete the Counseling Professional questions
Counseling Professional Form (CP) Amount $
within the Rating and Underwriting section of the application.)

Damage to Premises Rented to You $300,000 + $9,999 = $309,999

Directors, Officers and Trustees Liability Amount $ 9,999

Note: Counseling Professional Liability is required when endorsing coverage for Directors, Officers and Trustees Liability.
(Please complete the Directors and Officers questions within the Rating and Underwriting section of the application.)

EA 2532 WI.1 Rev. 07-2022 Page 5 of 8 1007265 2014 148494 214 05-09-2023
 Exclude Employers Non-Owned Auto Liability

Hired Auto Liability Annual Cost of Hired Autos $ 999

Other XXX

Rating and Underwriting

Fully describe all the religious organization's business activities on and off premises.
XXX

Yes No
Are there other operations and / or other owned or leased locations?
If yes, explain:
XXX

Yes No
Does the religious organization own / operate any cemeteries? If yes, how many? 99
Yes No
Does the religious organization have any organized sports teams? If yes, how many? 99
Yes No
Does the religious organization have any gymnasiums? If yes, how many? 99
Yes No
Does the religious organization hold any fund-raising activities?
If yes, provide explanation in the space provided.
XXX

Yes No Number Number of

Does the religious organization operate a day care, pre-school or nursery? of children 99 teachers / assistants 9
Yes No
Is the day care, pre-school or nursery open to public?

Medical Payments coverage for day care, pre-school or nursery: Include Exclude

Yes No
Is any religious organization property or building rented to schools?
If yes, provide explanation in the space provided.
XXX

Yes No
Does the religious organization operate a grade or high school?
Number of Number of Number of teachers for
students in K-6: 99 students 7-12: 99 the grade or high school: 99
Medical Payments coverage for the grade or high school: Include Exclude

Yes No
Does the religious organization operate any summer camps?
If yes, provide how many of the following:

Number of camps 9 Number of teachers / assistants 9 Number of saddle animals 9

Number of motor sail boats 9 Number of outboard motors 9

Yes No
Are alcoholic beverages sold and / or consumed on premises?
If yes, explain:
XXX

Counseling Professional Liability - complete the following for each person engaged in counseling

EA 2532 WI.1 Rev. 07-2022 Page 6 of 8 1007265 2014 148494 214 05-09-2023
 Year
Name Position Name of Theological Seminary Attended Accredited Graduated

XXX XXX XXX Yes 9999

Yes No
Is there any Counseling Professional Liability claim or suit now pending against the church and / or clergy?
If yes, explain:
XXX

Is the religious organization or clergy aware of any act, error, omission, fact, circumstance or Yes No
situation which might afford valid grounds for future claim, suit or action as would fall within the scope of the proposed insurance?
If yes, explain:
XXX

Yes No
Are the clergy engaged in an income-producing counseling practice?

Directors, Officers and Trustees

The information for the section is to be provided by an officer of the organization
List all income-producing activities not related to usual church activities (e.g. farms, day nursery, etc.):
XXX

List all subsidiary organizations (e.g. schools, etc.):

XXX

Has there been or is there currently any litigation in the religious organization, or Yes No
in religious organization of its affiliated denomination, over a tax exemption or a denominational dispute?
If yes, explain:
XXX

Yes No
Does the religious organization sell or authorize the sale of any securities?
If yes, explain:
XXX

Premium / Payment Information Application taken: XX-XX-XXXX XX:XX PM

Initials of agent or licensed staff person taking the application:

SFPP Payment 1 Amount Payment 2 Amount

Paid $ Paid $
Yes No Cash Cash
Check Check
Check Number Check Number
Credit Card Reference Number Amount Credit from Balance Total
EFT Paid $ 9.00 other policy $ 9.00 Due $ 999.00 Premium $ 999.00

Billing Information
Yes No
Should named insured be billed for renewals?
Renewals will be billed to the name below.
XXX

Yes No
Should named insured be billed for endorsements?
Endorsements will be billed to the name below.
XXX

EA 2532 WI.1 Rev. 07-2022 Page 7 of 8 1007265 2014 148494 214 05-09-2023
Remarks
Scrubbed Remarks:XXXX

EA 2532 WI.1 Rev. 07-2022 Page 8 of 8 1007265 2014 148494 214 05-09-2023