1005 Grand Ave • PO Box 65665 •

West Des Moines, IA 50265 • 515.223.1197

File a Auto Claim

Person Reporting Incident

First Name

Last Name

Phone

Basic Claim Information

Name of Church/school that sponsored event

Date of Accident

Time of accident (if known)

Location of accident

Address Line 1

Address Line 2

City

State

Zip Code

Description/Nature of Accident/Incident

Was the accident reported to the police?

Yes

Date reported

Report number

Name of investigating organization?

Were any citations issued?

Yes

Church-Insured Vehicle Information

Year

Make

Model

VIN number

Name of registered owner

Name of driver

Drivers date of birth

Drivers Email

Drivers Phone number

Address

Address Line 1

Address Line 2

City

State

Zip Code

Reason for vehicle use at time of accident

Was the vehicle used with permission?

Yes

Was the driver injured?

Yes

Describe damage to vehicle

Address where the vehicle may be seen for an estimate

Address Line 1

Address Line 2

City

State

Zip Code

Were there any passengers in the church-insured vehicle?

Yes

How Many Passengers?

Passenger's Email

Name of passenger

Passenger's Phone Number

Address

Address Line 1

Address Line 2

City

State

Zip Code

Was the passenger injured?

Yes

Passenger's Email

Name of passenger

Passenger's Phone Number

Address

Address Line 1

Address Line 2

City

State

Zip Code

Was the passenger injured?

Yes

Passenger's Email

Name of passenger

Passenger's Phone Number

Address

Address Line 1

Address Line 2

City

State

Zip Code

Was the passenger injured?

Yes

Passenger's Email

Name of passenger

Passenger's Phone Number

Address

Address Line 1

Address Line 2

City

State

Zip Code

Was the passenger injured?

Yes

Passenger's Email

Name of passenger

Passenger's Phone Number

Address

Address Line 1

Address Line 2

City

State

Zip Code

Was the passenger injured?

Yes

Passenger's Email

Name of passenger

Passenger's Phone Number

Address

Address Line 1

Address Line 2

City

State

Zip Code

Was the passenger injured?

Yes

Passenger's Email

Name of passenger

Passenger's Phone Number

Address

Address Line 1

Address Line 2

City

State

Zip Code

Was the passenger injured?

Yes

Passenger's Email

Name of passenger

Passenger's Phone Number

Address

Address Line 1

Address Line 2

City

State

Zip Code

Was the passenger injured?

Yes

Passenger's Email

Name of passenger

Passenger's Phone Number

Address

Address Line 1

Address Line 2

City

State

Zip Code

Was the passenger injured?

Yes

Passenger's Email

Name of passenger

Passenger's Phone Number

Address

Address Line 1

Address Line 2

City

State

Zip Code

Was the passenger injured?

Yes

Passenger's Email

Name of passenger

Passenger's Phone Number

Address

Address Line 1

Address Line 2

City

State

Zip Code

Was the passenger injured?

Yes

Damaged Property and Other Vehicle Information

Type of damage

Describe damaged property

Describe damage to vehicle

Year

Make

Model

License plate number

Insurance company

Policy number

Name of driver

Drivers email address

Drivers phone number

Address

Address Line 1

Address Line 2

City

State

Zip Code

Was the driver injured?

Yes

Witnesses

Was there any witnesses?

Yes

How Many?

Name of Witness

Witness's Email

Witness's Phone

Witness's Address

Address Line 1

Address Line 2

City

State

Zip Code

Name of Witness

Witness's Email

Witness's Phone

Witness's Address

Address Line 1

Address Line 2

City

State

Zip Code

I certify that the information I have provided is truthful to the best of my knowledge.

File a Property Claim

Person Reporting Incident

This is who the insurance company will contact regarding the claim

First Name

Last Name

Phone

Church Information

Name of Church

Address

Address Line 1

Address Line 2

City

State

Zip Code

Claim Information

Type of Claim

if Other

Date of Loss and Time

Description/Nature of Accident/Incident

Was the Fire Department Called?

Yes

Are any portions of the property left exposed to the fire (classrooms or kitchen with missing walls, etc)

Yes

Has the water been removed?

Yes

Does the Church have a sump pump?

Yes

Descriptions of Stolen/damaged property

Name of investigating organization?

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone number of investigating organization

Name of contact person (if applicable)

Date reported

Report number

I certify that the information I have provided is truthful to the best of my knowledge.

Church Attendance Form

Attendance Report

This Report Should be Completed Each Month Following the Final Sabbath.

Month/Year Being Reported

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URL

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Forms and Reports

Human Resources Department

Membership / Clerk Forms

Membership Records / Clerk

Education

Evangelism

Adventurers

Pathfinders

Community

Find a Church

Find a School

Share a Story

Prayer Requests

Church Life

Background Checks

Forms and Reports

Calendar

Give Back

Online Giving

Planned Giving

Food Label Program

1st Sabbath

2nd Sabbath

3rd Sabbath

4th Sabbath

5th Sabbath

Forms and Reports

Employee Portal

Human Resources Department

Church Insurance

New Memebership/Status Change Reports

Membership / Clerk Forms

Church Attendance Forms

Department Forms

Membership Records / Clerk

Education

Evangelism

Adventurers

Pathfinders

Community

Find a Church

Find a School

Share a Story

Prayer Requests

Church Life

Background Checks

Forms and Reports

Calendar

Give Back

Online Giving

Planned Giving

Food Label Program

File a Auto Claim

Person Reporting Incident

Basic Claim Information

Church-Insured Vehicle Information

Damaged Property and Other Vehicle Information

Witnesses

File a Property Claim

Person Reporting Incident

Church Information

Claim Information

Attendance Report

Number of Sabbaths in the Month?

1st Sabbath

2nd Sabbath

3rd Sabbath

4th Sabbath

5th Sabbath