December 17, 2018
Long Insurance Services, LLC.

CHURCH AND RELIGIOUS INSTITUTIONS PROGRAM

Contact Information
Name of Church/Institution *
Address of Church/Institution *
Website Address of Church/Institution (if applicable) *
Contact Person*
Contact's Email Address *
Contact's Phone Number*
Contact's Fax Number
Coverages
  Current Carrier Expiration Date
Package (Includes Property Liability, Pastoral Liability)
Auto
Crime
Workers Compensation
Internet Liability
Umbrella Liability
* = Required Field