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Great Neck, NY 11021
516-466-4200 ( HYPERLINK "http://www.butwin.com/"www.butwin.com
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HYPERLINK "http://www.butwin.com/" CHURCH SUPPLEMENTAL APPLICATION
These supplemental questions are in addition to a HYPERLINK "http://www.butwin.com/allstate/forms/BOP.doc" \t "_blank" completed BOP application
Applicants Name: FORMTEX T
A g e n t : F O R M T E X T
A g e n t P h o n e # F O R M T E X T
A n y h o s p i t a l s , h o m e s f o r t h e a g e d , i n f i r m a r i e s , o r p h a n a g e s , r e h a b s e r v i c e s , s a n i t a r i u m s , c o n v a l e s c e n t h o m e s , a s y l u m s , o r n e w s - p a p e r / w e b p u b l i s h i n g ( o t h e r t h a n c h u r c h b u l l e t i n s ) associated with the church? FORMCHECKBOX Yes FORMCHECKBOX NoDay care operations, other than used during religious services? FORMCHECKBOX Yes FORMCHECKBOX NoCemetery at the premises? FORMCHECKBOX Yes FORMCHECKBOX NoCooking on the premises? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, grills? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, fryer? FORMCHECKBOX Yes FORMCHECKBOX NoThrift-shop operation in the church? FORMCHECKBOX Yes FORMCHECKBOX NoPremises rented out to any other functions? FORMCHECKBOX Yes FORMCHECKBOX NoGym on premises? FORMCHECKBOX Yes FORMCHECKBOX NoResidence on premises? FORMCHECKBOX Yes FORMCHECKBOX NoPlayground on premises? FORMCHECKBOX Yes FORMCHECKBOX NoHomeless shelter on premises? FORMCHECKBOX Yes FORMCHECKBOX NoSchool (K-12) on premises? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, lease or own buses or vans? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, conduct/sponsor interscholastic sports? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, conduct/sponsor travel or overnight trips? FORMCHECKBOX Yes FORMCHECKBOX NoOwn or operate camps? FORMCHECKBOX Yes FORMCHECKBOX NoFor any child or youth activity, are two (2) adults always present? FORMCHECKBOX Yes FORMCHECKBOX NoDo they sponsor any outside functions? FORMCHECKBOX Yes FORMCHECKBOX No B C D E g h i w x y z nVnBn &0J 56>* B*CJ OJ QJ aJ ph .jZ 56B*CJ OJ QJ UaJ ph (j 56B*CJ OJ QJ UaJ ph 56B*OJ QJ aJ ph 6B*CJ OJ QJ aJ ph
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