Church #(Required)

Church name(Required)

Church address(Required)

Street Address Address Line 2 City

State ZIP Code

Was an insurance claim filed?(Required)

Yes

If claim was filed, enter claim #(Required)

Has an adjuster been to the church and provided a statement of loss?(Required)

Yes

If adjuster has been to the church, what is the replacement cost value on the statement of loss?(Required)

If no, do you have an estimated time of when the adjuster will review your case?

Have you had a contractor look at the damage and have your received an estimate?

Yes

If yes, how much is the estimate and what repairs are needed?

Insurance payment received.

*for those who have already received payment.

The insurance company will provide some payment. How much can the church raise?(Required)

How much grant or additional funding might you request?(Required)

Trustee Chair Name

*please enter if known

Trustee Chair Email Address

* please enter if known

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City

State ZIP Code

Email(Required)

For more information, please contact:

Alexa Taylor

Insurance and Benefits Manager