Risk Placement Services

550 West Van Buren

Suite 1200
Chicago, IL 60607
Ph: 312-803-6324
Fax: 312-803-6309

The coverage outlined above may not conform

to the terms and conditions you requested.

Please check carefully. If this policy is being

quoted on a non-admitted basis, then all

applicable taxes and fees must be added to

the bound premium. If bound, your office will

be responsible for collecting Surplus Lines

taxes and fees (if applicable) from the insured,

in addition to completing any required Surplus

Lines forms. RPS will remit the applicable

taxes and forms to the state. If bound with

RPS, this policy will be subject to the Surplus

Lines laws in your state, therefore you should

make every effort to comply with any special

provisions and regulations of your state.

 Wilson J Insurance Agency, LLC

wilsonjinsuranceagency@hotmail.com

Enclosed you will find an admitted Non Profit Package quote for Iglesia Pentecoastal Refugio De Gloria Inc.. The quote
number is NPP025Y8668.

Section I- Details the premiums, taxes and fees associated with this account. In addition, it provides the
Underwriting Notes and covers any of the additional underwriting information that might be needed
prior to binding or within 21 days of the inception date.
Section II- Summarizes the locations, building information, property coverages, warranties, and the corresponding
classifications with the exposures and rates.
Section III- Provides the Liability Limits of Insurance
Section IV- Lists the required coverage forms, notices, endorsements and exclusions.
Section V- Offers optional coverages that are available to the applicant but are not currently included in the quote.
Section VI- Provides the Direct Bill Payment Description.

In addition we have included some materials that will assist in the evaluation of this offer of coverage.
An Excess General Liability quote that provides higher limits of Liability. It is attached as a separate quote under
#XSL025Y15H0. This quote is optional and not required to be bound along with the primary quote. If coverage is
desired, we would issue a separate policy.
A pre-filled application that includes the information you have already provided.
Endorsement TRIADN MA Disclosure Notice of Terrorism Insurance Coverage for your review.
A Point of Sale piece that provides some claims scenarios this account may encounter and a coverage checklist
that can be compared to the quotation of another carrier.

The carrier will send you an invoice based on the terms reflected in this quote.
Payment is due to the carrier.

Payment options available to you are:

1. Send the invoice remittance slip with payment to the lockbox address on their invoice
2. Pay online at <www.usli.com/ezpay>.
3. Pay by phone (automated system available 24/7) at 866-632-2003

Your invoice will include a unique number that will allow you to register your policy at <www.usli.com/ezpay>. By registering
your policy, you will have access to additional information as well as the option to set-up recurring payments. Recurring
payments are a great way to minimize the possibility of your policy being cancelled or not renewed because payment was
not received.

We invite you to contact us to discuss the benefits of any coverages, the costs associated or simply to provide
feedback! We welcome the opportunity to talk with you about this quote.
Cover letter
 Wilson J Insurance Agency, LLC

wilsonjinsuranceagency@hotmail.com

feedback! We welcome the opportunity to talk with you about this quote.

Thank you for the opportunity to quote this account!

Sincerely,
Wilson J Osorio
Wilson J Insurance Agency, LLC

Cover letter
 Wilson J Insurance Agency, LLC

wilsonjinsuranceagency@hotmail.com

NPP025Y8668

Quote is valid until 7/14/2025 Please bind effective:

Insured email address:
Insured phone number:
To: Iglesia Pentecoastal Refugio De Gloria Inc.
Confirm optional coverages:
Do not include any optional coverages.
Include the following optional coverages
(Taxes & Fees may apply to optional premium if purchased)
Option 1 - (add: *$100.00) - Terrorism Coverage
*See Terrorism Section for Exact Pricing and Terms

This policy is eligible to be Direct Billed.

From: Wilson J Osorio Note: a $5.00 installment fee will apply to each installment after
the first - please select one of the following:

wilsonjinsuranceagency@hotmail.com Direct Bill both this New Business and future Renewals
(If checked - Select a Payment Plan):
SINGLE PAYMENT
TWO PAYMENTS - Premium must be over $400
See the last page of this quote for Payment Plan Descriptions
Do not Direct Bill this New Business but do Direct Bill
future Renewals
Do not Direct Bill this policy
NOTE: If the Direct Bill Option is selected, the Company
will invoice the insured. Do not bill or collect the down
payment. All taxes, surcharges and fees (except
installment fees) will be billed in full with the first
installment.

Bind Excess Liability At $1,000,000 - Inquire for higher

limits.

See attached Quote #XSL025Y15H0 (separate billing applies).

I. PREMIUM AND UNDERWRITING NOTES/REQUIREMENTS

NON PROFIT PACKAGE POLICY INFORMATION

Carrier: Mount Vernon Fire Insurance Company
Status: Admitted
A.M. Best Rating: A++ (Superior) - XIV
COVERAGE PART PREMIUM
Commercial General Liability $500.00
PLEASE REFER TO THE EXCESS LIABILITY QUOTE #XSL025Y15H0 IF HIGHER
LIMITS OF LIABILITY ARE DESIRED.

TOTAL PREMIUM DUE TO CARRIER $500.00

ADDITIONAL COSTS
Wholesaler Broker Fee $100.00
TOTAL AMOUNT DUE $600.00
Please contact us with any questions regarding the terminology used or the coverages provided.
**Read the quote carefully, it may not match the coverages requested**

Page 1 of 4
 NPP025Y8668

FREE AND DISCOUNTED BUSINESS SERVICES AVAILABLE TO USLI INSUREDS – VISIT BIZRESOURCECENTER.COM FOR DETAILS

This account is subject to the following - Sections A, B and C:

Please note that we will not be able to bind coverage until we satisfy all Prior to Binding requirements.
Underwriter receipt, review and acceptance of the fully completed application. We may modify the terms and/or premiums quoted or
rescind this quote if: 1) the information provided in the completed application is different from the original submission, 2) a web search,
if completed at our discretion, reveals unsatisfactory results or indications of ineligible factors, or 3) there is a significant change in the
risk from the date it was quoted.

A. Prior To Bind Requirements:

No Prior to Bind Requirements

B. Items Required Within 21 days of the inception of coverage:

Our completed & signed application as long as all underwriting information needed has been provided to us; or
A completed & signed ACORD application as long as all underwriting information needed has been provided to us; or
A completed & signed application from another company as long as all underwriting information needed has been provided to us.

C. Underwriting Notes:
Additional limits for Abuse and Molestation coverage may be available. Please contact your underwriter for alternate limit options.

II. COVERED LOCATION(S) AND CORRESPONDING CLASSIFICATIONS

Location #1 - 84 Pleasant St, Worcester, MA 01609
Liability Coverage
Description Class Basis Exposure Prod/CompOps All Other Prod/CompOps All Other
Code Rate Rate Premium Premium
Abuse & Molestation Liability- 41794 Flat Incl 25.000 Incl $25
Church-Defense Outside Limits Flat
Additional Insured - Church Members / 49950 Flat 1 Incl 0.000 Incl Incl
Officers
Flat
Churches or other Houses of Worship 41650 Total Area 1,000 Incl 62.351 Incl $62

Per 1,000
Total Area
Pastoral Professional Liability 72991 Flat Incl 250.000 Incl $250
Flat
Liability Coverage Premium for Location #1: $500 MP

III. LIABILITY LIMITS OF INSURANCE

COMMERCIAL GENERAL LIABILITY MOLESTATION OR ABUSE DEFENSE OUTSIDE LIMIT
Each Occurrence $1,000,000 Each Claim $100,000
Personal Injury and Advertising Injury $1,000,000 Aggregate $300,000
Medical Expense (Any One Person) $5,000
Damage To Premises Rented to You $100,000 PASTORAL PROFESSIONAL LIABILITY
Products/Completed Ops Aggregate Included Each Claim $1,000,000
General Aggregate $2,000,000 Aggregate Limit $1,000,000
General Liability Deductible $0

Please contact us with any questions regarding the terminology used or the coverages provided.
**Read the quote carefully, it may not match the coverages requested**

Page 2 of 4
 NPP025Y8668
IV. REQUIRED FORMS & ENDORSEMENTS
General Liability Endorsements
CG 21 06 (12/23) Exclusion - Access or Disclosure of L-433 (02/11) Trampoline Or Rebounding Device
Confidential or Personal Material or Information Exclusion
CG0001 (12/07) Commercial General Liability Coverage L-472 (07/08) Exclusion - Injury To Performers Or
Form Entertainers
CG0068 (05/09) Recording And Distribution Of Material Or L-549 (12/07) Absolute Professional Liability Exclusion
Information In Violation Of Law Exclusion
CG2022 (10/01) Additional Insured - Church Members And L-599 (10/12) Absolute Exclusion for Pollution, Organic
Officers Pathogen, Silica, Asbestos and Lead with a
Hostile Fire Exception
CG2132 (05/09) Communicable Disease Exclusion L-607 (02/11) Exclusion For Climbing, Rebounding And
Interactive Games And Devices
CG2136 (03/05) Exclusion - New Entities L-608 (02/11) Exclusion For Firearms, Fireworks And
Other Pyrotechnic Devices
CG2139 (10/93) Contractual Liability Limitation L-609 (02/11) Animal Exclusion
CG2147 (12/07) Employment-Related Practices Exclusion L-610 (11/04) Expanded Definition Of Bodily Injury
CG2173 (01/15) Exclusion Of Certified Acts Of Terrorism L-703 DOL (12/15) Molestation or Abuse Insurance
(Defense Outside Limits)
CG2230 (07/98) Exclusion - Corporal Punishment L-716 (05/15) Pastoral Professional Liability Insurance
CG4032 (05/23) Exclusion - Perfluoroalkyl and L-734 NPP (10/16) Exclusion-Specific Activities, Events or
Polyfluoroalkyl Substances (PFAS) Conditions
IL0017 (11/98) Common Policy Conditions L-756 (08/11) Exclusion - Sponsored Athletic Programs
Or Competition
IL0021 (09/08) Nuclear Energy Liability Exclusion L-767 NPP (11/11) Exclusion - Bleacher Collapse
Endorsement
Jacket (07/19) Policy Jacket L-783 NPP (07/18) Amendment of Liquor Liability Exclusion
L-224 (10/10) Punitive Or Exemplary Damages LLQ-100 MA (07/06) Who Is An Insured Clarification
Exclusion Endorsement
L-232s (09/05) Classification Limitation Endorsement LLQ-368 (08/10) Separation Of Insureds Clarification
Endorsement
L-278CH (03/14) Independent Contractors/Subcontractors TRIADN MA (12/20) Disclosure Notice of Terrorism Insurance
Exclusion Coverage
L-387 (03/06) Exclusion - Mechanical Rides

V. OFFER OF OPTIONAL COVERAGE(S)

Based on the information provided, the following additional coverages are available to this applicant but are not currently included in the
quotation. The additional premium may be subject to taxes & fees. For a firm final amount please contact us and we will revise the quote.
Coverage Additional Premium
Option 1 Terrorism Coverage $100.00

Important Information
Terrorism coverage, per the Terrorism Risk Insurance Program Reauthorization Act, is available for an
additional premium of $100 or 5.00% of the total applicable premium, whichever is greater. If not purchased,
please provide the signed TRIADN Disclosure Notice or add form NTE - Notice of Terrorism Exclusion. When
making your decision to purchase Terrorism Coverage, please be aware that coverage for "insured losses" as
defined by the Act is subject to the coverage terms, conditions, amount, and limits in this policy applicable to
losses arising from events other than acts of terrorism.
The Terrorism premium shown above has been calculated as a percentage of the quoted coverages. If any
coverages are added or removed at binding, the additional premium shown above is subject to change.
VI. DIRECT BILL PAYMENT PLAN DESCRIPTIONS
One Year Payment Plan Descriptions:
SINGLE PAYMENT - The entire premium is invoiced immediately.
TWO PAYMENTS - 50% of the premium is invoiced immediately; the balance is invoiced approximately 5 months after inception.

Please contact us with any questions regarding the terminology used or the coverages provided.
**Read the quote carefully, it may not match the coverages requested**

Page 3 of 4
 NPP025Y8668
A detailed installment schedule will be included with the first invoice. An installment fee as noted on page 1 of this quote applies to
each installment after the first.

Please contact us with any questions regarding the terminology used or the coverages provided.
**Read the quote carefully, it may not match the coverages requested**

Page 4 of 4
 Wilson J Insurance Agency, LLC

wilsonjinsuranceagency@hotmail.com

Enclosed you will find an annual admitted Excess General Liability Coverage for Iglesia Pentecoastal Refugio De Gloria Inc..
The quote number is XSL025Y15H0.

Section I- Details the premiums, taxes and fees associated with this account. In addition, it provides the
Underwriting Notes and covers any of the additional underwriting information that might be needed
prior to binding or within 21 days of the inception date.
Section II- Schedule of Underlying Coverages
Section III- Lists the required coverage forms, notices, endorsements and exclusions.
Section IV- Offers optional coverages that are available to the applicant but are not currently included in the quote.
Section V- Provides the Direct Bill Payment Description.

In addition we have included some materials that will assist in the evaluation of this offer of coverage.
A pre-filled application that includes the information you have already provided.
Endorsement TRIADN MA Disclosure Notice of Terrorism Insurance Coverage for your review.
A Point of Sale piece that provides some claims scenarios this account may encounter and a coverage checklist
that can be compared to the quotation of another carrier.

The carrier will send you an invoice based on the terms reflected in this quote.
Payment is due to the carrier.

Payment options available to you are:

1. Send the invoice remittance slip with payment to the lockbox address on their invoice
2. Pay online at <www.usli.com/ezpay>.
3. Pay by phone (automated system available 24/7) at 866-632-2003

Your invoice will include a unique number that will allow you to register your policy at <www.usli.com/ezpay>. By registering
your policy, you will have access to additional information as well as the option to set-up recurring payments. Recurring
payments are a great way to minimize the possibility of your policy being cancelled or not renewed because payment was
not received.

We invite you to contact us to discuss the benefits of any coverages, the costs associated or simply to provide
feedback! We welcome the opportunity to talk with you about this quote.

Thank you for the opportunity to quote this account!

Sincerely,
Wilson J Osorio
Wilson J Insurance Agency, LLC
Cover letter
 Wilson J Insurance Agency, LLC

wilsonjinsuranceagency@hotmail.com

XSL025Y15H0

Quote is valid until 7/14/2025 Please bind effective:

Insured email address:
Insured phone number:
To: Iglesia Pentecoastal Refugio De Gloria Inc.
Confirm optional coverages:
Do not include any optional coverages.
Include the following optional coverages
(Taxes & Fees may apply to optional premium if purchased)
Option 1 - Terrorism Coverage

This policy is eligible to be Direct Billed.

Note: a $5.00 installment fee will apply to each installment after
the first - please select one of the following:
From: Wilson J Osorio
Direct Bill both this New Business and future Renewals
wilsonjinsuranceagency@hotmail.com (If checked - Select a Payment Plan):
SINGLE PAYMENT
TWO PAYMENTS - Premium must be over $400
THREE PAYMENTS - Premium must be over $675
FOUR PAYMENTS - Premium must be over $1,000
See the last page of this quote for Payment Plan Descriptions
Do not Direct Bill this New Business but do Direct Bill
future Renewals
Do not Direct Bill this policy
NOTE: If the Direct Bill Option is selected, the Company
will invoice the insured. Do not bill or collect the down
payment. All taxes, surcharges and fees (except
installment fees) will be billed in full with the first
installment.

I. PREMIUM AND UNDERWRITING NOTES/REQUIREMENTS

EXCESS GENERAL LIABILITY COVERAGE POLICY INFORMATION

Carrier: Mount Vernon Fire Insurance Company
Status: Admitted
A.M. Best Rating: A++ (Superior) - XIV
Term Quoted: Annual
LIMIT OPTIONS PREMIUM FEES AMOUNT DUE
$1,000,000 $295 (MP) $100.00 $395.00

ADDITIONAL COSTS
Wholesaler Broker Fee $100

FREE AND DISCOUNTED BUSINESS SERVICES AVAILABLE TO USLI INSUREDS – VISIT BIZRESOURCECENTER.COM FOR DETAILS

We have provided a pre-filled application that would assist in satisfying these requirements.

This account is subject to the following - Sections A, B and C:

Please contact us with any questions regarding the terminology used or the coverages provided.
**Read the quote carefully, it may not match the coverages requested**

Page 1 of 3
 XSL025Y15H0
This account is subject to the following - Sections A, B and C:
Please note that we will not be able to bind coverage until we satisfy all Prior to Binding requirements.
Underwriter receipt, review and acceptance of the fully completed application. We may modify the terms and/or premiums quoted or
rescind this quote if: 1) the information provided in the completed application is different from the original submission, 2) a web search,
if completed at our discretion, reveals unsatisfactory results or indications of ineligible factors, or 3) there is a significant change in the
risk from the date it was quoted.

A. Prior To Bind Requirements:

Confirmation that all of the following are True:
There are no past, pending or planned foreclosure and/or bankruptcy or judgment for unpaid taxes against the named insured or any
officer, partner, member or owner, individually within the past five years.
Insurance coverage has not been cancelled or non-renewed in the past three years (not applicable in MO).
Every floor with public access has at least two means of egress (exits).
No actual or alleged molestation or abuse incidents in the past and none currently under investigation.
Operations do not include soup kitchen, food bank, thrift store, cemetery or shelter.

B. Items Required Within 21 days of the inception of coverage:

No 21 Day Subject to Notes

C. Underwriting Notes:
Please be advised, we have prepared this quote of higher limits of liability based on the information provided for a primary quote. It is
valid only over the United States Liability Insurance Group quote provided, however we can consider adjusting it to be valid over other
carriers. In addition, we can possibly include other lines of coverage in the underlying such as Automobile Liability and Employer's
Liability.
Please contact me if you wish to discuss further.
II. SCHEDULE OF UNDERLYING COVERAGES

Commercial General Liability Limits of Liability

Carrier: Mount Vernon Fire Insurance Company Each Occurrence: $1,000,000
AM Best Rating: A++g Products/Completed Operations Included
Aggregate:
General Aggregate: $2,000,000
Personal & Advertising Injury: $1,000,000

III. REQUIRED FORMS & ENDORSEMENTS

IUL100 (07/06) Expected or Intended Injury Exclusion TRIADN MA (12/20) Disclosure Notice of Terrorism Insurance
Coverage
IUL117 (09/10) Nuclear Energy Liability Exclusion (Broad XL MA (07/20) Excess Liability Policy
Form)
IUL124MA (01/12) Communicable Disease Or Sickness XL101 (05/07) Automobile Exclusion
Exclusion
IUL134MA (01/12) Mechanical Rides Exclusion XL462MA (01/12) Molestation Or Abuse Exclusion
IUL137MA (01/12) Trampoline Or Rebounding Device XL463MA (01/12) Absolute Professional Liability Exclusion
Exclusion
Jacket (07/19) Policy Jacket XL465 (12/16) Exclusion - Unmanned Aircraft
L 838 PFAS (03/23) Exclusion - Perfluoroalkyl And XL542 (12/20) Exclusion of War and Certified Acts of
Polyfluoroalkyl Substances (PFAS) Terrorism

Please contact us with any questions regarding the terminology used or the coverages provided.
**Read the quote carefully, it may not match the coverages requested**

Page 2 of 3
 XSL025Y15H0
IV. OFFER OF OPTIONAL COVERAGE(S)
Based on the information provided, the following additional coverages are available to this applicant but are not currently included in the
quotation. The additional premium may be subject to taxes & fees. For a firm final amount please contact us and we will revise the quote.
Coverage Rate
Option 1 Terrorism Coverage See notes for rate information

Important Information
Terrorism coverage, per the Terrorism Risk Insurance Program Reauthorization Act, is available for an
additional premium of $100 or 5.0000% of the total applicable premium for this risk, whichever is greater. If not
purchased, please provide the signed TRIADN Disclosure Notice or add form NTE – Notice of Terrorism
Exclusion. When making your decision whether to purchase Terrorism Coverage, please be aware that
coverage for "insured losses" as defined by the Act is subject to the coverage terms, conditions, amount and
limits in this policy applicable to losses arising from events other than acts of terrorism.
Coverage available under this offer is contingent on the underlying policies providing terrorism coverage and at
the same limit as the Schedule of Underlying Coverages
V. DIRECT BILL PAYMENT PLAN DESCRIPTIONS
One Year Payment Plan Descriptions:
SINGLE PAYMENT - The entire premium is invoiced immediately.
TWO PAYMENTS - 50% of the premium is invoiced immediately; the balance is invoiced approximately 5 months after inception.

THREE PAYMENTS - 40% of the premium is invoiced immediately; the balance is invoiced in two equal installments approximately 4
months and 7 months after inception.
FOUR PAYMENTS - 40% of the premium is invoiced immediately; the balance is invoiced in three equal installments approximately 4
months, 6 months, and 8 months after inception.

A detailed installment schedule will be included with the first invoice. An installment fee as noted on page 1 of this quote applies to
each installment after the first.

Please contact us with any questions regarding the terminology used or the coverages provided.
**Read the quote carefully, it may not match the coverages requested**

Page 3 of 3
 Mount Vernon Fire Insurance Company

NPP025Y8668
Houses of Worship Supplemental Application
Please complete all sections of this application and have signed by the applicant.

GENERAL INFORMATION
Name Of Organization: Iglesia Pentecoastal Refugio De Gloria Inc.
Mailing Address: 84 Pleasant St
City: Worcester State: MA Zip Code: 01609
Location Address: 84 Pleasant St Same as mailing address
City: Worcester State: MA Zip Code: 01609
Website Address: Email Address: iprefugiodegloria@gmail.com

APPLICANT ELIGIBILITY
Are there past, pending or planned foreclosures and/or bankruptcies or judgments for unpaid taxes against the Yes No
named insured or any officer, partner, member or owner, individually within the last five years?
Has Insurance coverage been cancelled or non-renewed in the past three years? (not applicable in MO) Yes No
Are there at least two means of egress (exits) for every floor with public access? Yes No
Does the organization engage in any international travel or activities? Yes No
Are individuals under the age of 18 permitted on international trips? Yes No
Have there been any actual or alleged molestation or abuse incidents in the past or are there any currently under Yes No
investigation?
Do operations include a commercial child care center, grade/high school, convent, monastery, missionary housing, Yes No
retreat house, retreat center or campground?
Do operations include a soup kitchen, food bank, thrift store, cemetery or shelter? Yes No

LOCATIONS OF COVERAGES AND CORRESPONDING CLASSIFICATIONS

Location #1
Address City State Zip
84 Pleasant St Worcester MA 01609

UNDERWRITING INFORMATION FOR LOCATION #1

Classification Premium Basis Exposure Applicable Sq. Ft.
Abuse & Molestation Liability- Church-Defense Outside Limits Flat 0

Additional Insured - Church Members / Officers Flat 1

Churches or other Houses of Worship Total Area 1000 N/A

Pastoral Professional Liability Flat 0

GENERAL LIABILITY ELIGIBILITY

Do all public areas, occupancies and/or habitational units have functioning and operational smoke and/or heat Yes No
detectors?
For any building built prior to 1978, is 100 percent of the wiring on functioning and operational circuit breakers? Yes No
Are all exit signs on the premises illuminated? Yes No
Are any renovations or other construction projects anticipated in the next 12 months? Yes No
Classification
Abuse & Molestation Liability- Church-Defense Outside Limits
Are all prospective employees required to have their prior employment and personal references verified? Yes No
Except for a bona-fide counseling session, are minors ever left alone with only one adult in any program, service, Yes No
event or other church sponsored activity?
SCCP SUP_APP - United States Liability Insurance Group
event or other church sponsored activity?
Is there a policy/procedure that is followed for the proper supervision of employees and volunteers who are in Yes No
direct contact with minors and other individuals in all programs, services, events or other church activities?
Does the hiring process for employees/volunteers include questions about whether the individual has ever been Yes No
convicted of any crime or involved in any lawsuit, claim or charge involving sexual abuse, sexual molestation or
sexual misconduct?
Classification
Pastoral Professional Liability

Check Limit Option that applies (can not exceed GL Limit):

$100,000 $300,000 $500,000 $1,000,000
Does the Organization have more than 5 pastors/clergy on staff at any one location? Yes No
Are there procedures in place to protect the confidentiality of church members? Yes No
Are there any prior allegations, claims, or suits as a result of counseling services? Yes No

LOSS HISTORY
Liability Please provide detail below

Year Status Incurred Description

2024-2025 None
2023-2024 None
2022-2023 None

Fraud Statement (All Other States): Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly
presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

Retail Agency Name: Wilson J Insurance Agency, LLC License #:

Main Agency Phone Number:
Agency Mailing Address:
City: State: Zip:
The signer of this application acknowledges and understands that the information provided in this Application is material to the Insurer’s decision to
provide the requested insurance and is relied on by the Insurer in providing such insurance. The signer of this application represents that the information
provided in this Application is true and correct in all matters. The signer of this Application further represents that any changes in matters inquired about in
this Application occurring prior to the effective date of coverage, which render the information provided herein untrue, incorrect or inaccurate in any way
will be reported to the Insurer immediately in writing. The Insurer reserves the right to modify or withdraw any quote or binder issued if such changes are
material to the insurability or premium charged, based on the Insurer’s underwriting guides. The Insurer is hereby authorized, but not required, to make
any investigation and inquiry in connection with the information, statements and disclosures provided in this Application. The decision of the Insurer not to
make or to limit any investigation or inquiry shall not be deemed a waiver of any rights by the Insurer and shall not estop the Insurer from relying on any
statement in this Application in the event the Policy is issued. It is agreed that this Application shall be the basis of the contract should a policy be issued
and it will be attached and become a part of the Policy.
Applicant's Signature: Title: Date:

SCCP SUP_APP - United States Liability Insurance Group

 DISCLOSURE NOTICE OF TERRORISM INSURANCE
COVERAGE
You are hereby notified that under the Terrorism Risk Insurance Act ("the Act"), as amended, you
have a right to purchase insurance coverage for losses arising out of acts of terrorism. As defined in
Section 102(1) of the Act: The term “act of terrorism” means any act or acts that are certified by the
Secretary of the Treasury, in consultation with the Secretary of Homeland Security, and the Attorney
General of the United States, to be an act of terrorism; to be a violent act or an act that is dangerous
to human life, property, or infrastructure; to have resulted in damage within the United States, or
outside the United States in the case of certain air carriers or vessels or the premises of a United
States mission; and to have been committed by an individual or individuals, as part of an effort to
coerce the civilian population of the United States or to influence the policy or affect the conduct of the
United States Government by coercion.

You should know that any coverage for losses caused by certified acts of terrorism is partially
reimbursed by the United States under a formula established by federal law. Under this formula, the
United States reimburses 80% of covered terrorism losses exceeding the statutorily established
deductible paid by the insurance company providing the coverage. The premium charged for this
coverage is provided below and does not include any charges for the portion of loss covered by the
federal government under the Act.

Coverage for "insured losses”, as defined in the Act, is subject to the coverage terms, conditions,
amounts and limits in this policy applicable to losses arising from events other than acts of terrorism.

You should know that the Act, as amended, contains a $100 billion cap that limits U.S. Government
reimbursement, as well as insurers' liability, for losses resulting from certified acts of terrorism when
the amount of such losses in any one calendar year exceeds $100 billion. If the aggregate insured
losses for all insurers exceed $100 billion, your coverage may be reduced.

You should also know that, under federal law, you are not required to purchase coverage
for losses caused by certified acts of terrorism.

REJECTION OR SELECTION OF TERRORISM INSURANCE COVERAGE

Please “X” one of the boxes below and return this notice to the Company

I decline to purchase Terrorism Coverage. I understand that I will have no

coverage for losses arising from acts of Terrorism.
I elect to purchase coverage for certified acts of Terrorism for a premium of
$_____________.

Note: if you do not respond to our offer and do not return this notice to the
Company, you will have no Terrorism Coverage under this policy.

___________________________________ ____________________________
Applicant Name (Print) Name Insured

___________________________________ ____________________________
Authorized Signature Date

TRIADN MA (12-20) Page 1 of 1

As a policyholder through USLI, you have access to many free and discounted services that will assist you in operating
and growing your business through the Business Resource Center (BRC). Consider the following services and associated
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criminal searches and more (first background • Retail and professional services
check is free) • Youth services and child care
• Best practices for performing a background check • ... and more!
• Discounted tenant and drug screenings and motor
vehicle reports (MVRs)

Disaster Preparation and Recovery Try our cost-savings calculator

• Guidance on preparing for natural disasters and to see how much you could save!
serve weather
• Business planning and recovery toolkit
• Sample incident reporting form and disaster loan
assistance resource ONLINE LEARNING

Human Resources Need help training your new

• Free PeopleSystems’ human resources consultation employees?
helpline to be used for personnel issues, including Properly preparing new employees can be
harassment and discrimination, the Family and time-consuming and expensive. We offer a variety of
Medical Leave Act, disability, wage and hours free and discounted industry-specific training and
regulations and more certifications to help you save time and money!
• Online library with information, forms and articles
pertaining to human resources Topics include:
• Discounted HR and payroll management system • Food manager and handler safety
by PrimePoint • Liquor safety
• Discounted employee workplace assessment by • CPR, first aid and concussion
Talogy, previously PSI Caliper • Sexual harassment
• Resources for recruiting, interviewing and • Leadership and professional development
terminating employees

Marketing
• Resources marketing via email and social media,
capturing leads and building surveys For a full list of vendors,
• Free and discounted stock imagery sites and photo discounts and resources,
and video editing programs
visit bizresourcecenter.com.
• Discount stationery, signage, promotional items
and gifts

BRC-Quote and Policy 12/23

 UNITED STATES LIABILITY INSURANCE GROUP USLI.COM
A BERKSHIRE HATHAWAY COMPANY 888-523-5545

Storefront/Community Churches
Our broad policy is designed to meet the needs of all types of religious faiths and denominations with the opportunity to include general
liability, property insurance, directors and officers liability and employment practices liability

Why does your church need to purchase all of these coverages?

X Church board members can be sued for the decisions they make
X Employment-related laws are the same for any type of organization
X Most churches have an annual budget that is less than the average cost to defend a claim by litigation
X Churches have a large general liability and property exposure

Why should you choose the USLI’s Storefront/Community Churches Product?

X Maximize efficiency: One application, one quote, one underwriter, one policy, one renewal, one carrier for all claims, with one
concurrent effective date

OUR COMPETITORS’
COVERAGE FEATURES
GROUP POLICY

Separate limits of liability for directors and officers, employment

practices liability and general liability 3 ?
Defense outside the limit of liability for directors and officers,
employment practices liability 3 ?
Third party sexual harassment and third party
discrimination coverage for employment practices liability 3 ?
Mental anguish and emotional distress included in the general
liability definition of bodily injury 3 ?
Abuse and molestation sub-limit and pastoral professional
included in the general liability limits 3 ?
Functional building cost available
3 ?
Equipment breakdown coverage available
3 ?
Value Plus Endorsement – 14 valuable coverage enhancements
including water back-up, money and securities, employee
dishonesty, signs, transit and more 3 ?

Why choose to be insured with USLI?

X One of only 20 A++ rated insurance groups in the United States by A.M. Best.
X A proud member of the Berkshire Hathaway Group, recently voted the #1 most admired property and casualty company in
the world (Fortune Magazine).

Insure your financial well-being with a stable company that will be there to pay your claim.

This document does not amend, extend or alter the coverage afforded by the policy. For a complete understanding of any insurance you purchase, you must first read your policy,
declaration page and any endorsements and discuss them with your agent. A sample policy is available from your agent. Your actual policy conditions may be amended by
endorsement or affected by state laws.
SCC-POS 09/14
 USLI.COM
888-523-5545

Houses of Worship Product

Claim Examples

u Nonprofit Directors and Officers: A church elder breached u Property: A fire destroyed a church sanctuary, resulted in
his duty of loyalty by organizing a majority of the congregation smoke and water damage to the structure and contents of
into a separate church that ousted the remaining congregation the administrative office. In addition to replacing fixtures,
from the church property. The elder held secret meetings furnishings, equipment and inventory, the church needed to
among his supporting faction and prepared legal documents rent space for worship services until the sanctuary was rebuilt.
to transfer the property, all without informing the church’s u Pastoral Professional: The wife of a married couple sought
pastor of his plans. The court ruled that the elder owed a duty counseling services from their pastor due to being physically
to the whole congregation, and could not favor the interests abused in the household. The victim was contemplating
of the majority over the minority. As a result, the property was divorce and sought advice. The pastor encouraged the wife
returned to the original congregation and money damages to stay with her husband due to the sanctity of marriage in
were assessed personally against the elder. God’s eyes and to seek couples counseling. As a result,
With its membership growing rapidly, a church’s board of the wife went back to the abusive relationship and was later
directors appointed a new building committee to find land for a hospitalized with severe injuries from her husband. She then
larger church. The board selected one of its members to head sued the church and pastor stating that, as a result of the
the committee. That director steadily pressed the committee pastosr’s advice, she stayed in the unhealthy marriage which
to approve purchase of a land parcel viewed by the other led to her injuries.
committee members as pricey, but otherwise perfect. After u Abuse and Molestation: A Sunday School teacher was
much discussion, the committee approved the purchase, and accused of sexually molesting a teenager after a bible study
the transaction was completed. It was then discovered that the session. The teacher quickly denied the charges but was
head of the committee had a financial interest in the property. forced to step aside pending a church investigation. After a
Several congregants took action and named the committee thorough inquiry, the alleged victim’s credibility crumbled when
head and the overall board in a lawsuit alleging improper self- it was reported that she had a long history of inventing stories
dealing, negligence and fraudulent conduct. about herself and others. Moreover, the parents and students
u Employment Practices Liability: The director of Children’s who knew the teacher offered evidence that raised serious
Ministries was terminated and replaced. Her successor was a doubts that the molestations could have occurred. After an
younger Caucasian male, whom she believed was being paid exhausting investigation, the teacher was eventually reinstated
more than she was. She files suit with the EEOC against the to his duties. Defending the allegation with no merit was
Ministries, alleging racial discrimination, age discrimination, costly.
sex discrimination and pay discrimination. u Equipment Breakdown: A cracked section of a cast-iron
u General Liability: After the religious service, a congregant boiler resulted in replacement of the boiler, causing in $9,000
tripped on a crack in the concrete and tumbled down an of property damage and and extra expense at $1,500 to
outdoor flight of stairs, resulting in a concussion. relocate worship services to an available facility nearby.
A volunteer was decorating the church for a social gathering.
While she was standing on a chair to arrange the decorations,
she lost her balance and fell, resulting in severe arm injuries.

Policyholders have access to many services through our Business

Resource Center that will assist in growing and protecting their
nonprofit!

This document does not amend, extend or alter the coverage afforded by the policy. For a complete understanding of any insurance you purchase, you must first read your policy,
declaration page and any endorsements and discuss them with your agent. A sample policy is available from your agent. Your actual policy conditions may be amended by endorsement
or affected by state laws.
Houses of Worship-CE 3/15
 USLI.COM
888-523-5545

Houses of Worship Product

This all-in-one package is designed to meet the needs of your small house of worship operations. The product specializes in covering small
community, start-ups, storefront or inner city operations for all types of religious faiths and denominations.

Product Options: Additional Advantages:

u General liability u Quick quote turnaround
u Property coverage u Quick binder confirmation
u Directors and officers and employment practices liability u A.M. Best rated A++ carrier
u Low minimum premiums
General Liability: u Business Resource Center – free HR hotline with unlimited
u Pastoral professional coverage (up to $1,000,000 in limits) number of calls and no time limits plus discounted services
such as background checks and online HR training modules
u Abuse and molestation (up to $1,000,000 in limits)
u Personal and advertising coverage
u Hired and non-owned auto liability coverage available
u No designation premises endorsement
u No general liability deductible
u Optional certain criminal or civil proceeding defense cost
reimbursement coverage

Property Features:
u Value Plus Endorsement – 14 valuable coverage
enhancements including: $25,000 (fine arts), $10,000 (signs),
$10,000 (transit), $5,000 (money and securities), $5,000
(employee dishonesty) and more
u Special cause of loss form
u Optional equipment breakdown – includes free boiler inspection
if required in your jurisdiction

Directors and Officers/Employment Practices

Features:
u Separate limits of liability for directors and officers and
employment practices liability claims (directors and officers
limit not eroded by employment claims)
u Full prior acts coverage
u Third party discrimination and harassment coverage
u Defense cost outside the limit of liability
u Lifetime occurrence reporting provision – unlimited reporting
extension for former directors and officers who are not on
board when coverage is cancelled or not renewed
u Data & Security+ endorsement – $50,000 expense sub-limit
each for data breach, identity theft, workplace violence and
kidnap

This document does not amend, extend or alter the coverage afforded by the policy. For a complete understanding of any insurance you purchase, you must first read your policy,
declaration page and any endorsements and discuss them with your agent. A sample policy is available from your agent. Your actual policy conditions may be amended by endorsement
or affected by state laws.
HousesofWorship-NR 11/16
Privacy Notice At Collection
We may need to collect certain personal information to provide you with our services and products. For information
on how we store, use and protect personal information, please see our Privacy Policy accessible on our website,
https://www.usli.com/privacy-policy/.

Privacy Notice 11/21 – USLI page 1 of 1