Masonic Lodge Insurance Survey

Location Information
Lodge Name:
Lodge Number
Mailing Address:
Street Address:
City:
County:
State:
Zip Code:
Contact Information
Contact Person:
Phone Number:
Email Address:
Mailing Address:
City:
State:
Zip Code:
Structure Information
Date of Original Charter:
Age of Building:
Construction: Frame
Wood Joisted Masonry
Fire Resistant
Updates to Building: Wiring
Heating
Roof
Plumbing
Width of Building:
Length of Building:
Number of Stories:
Responding Fire Department:
Distance to Fire Department:
Number of Smoke Detectors:
Number of Fire Extinguishers:
List Kitchen Equipment:
Insurance Information
Name of Current Insurance Company:
Annual Premium:
Current Policy Renewal Date:
Current Amount of Insurance on Building:
Current Amount of Insurance on Contents:
Does OES Meet at the Lodge?: Yes  No
Has the fraternity filed a claim with your present insurance company in the past three years?
* = Required Field
Send