Directors and Officers Quote Form

January 16, 2013

Application for Non-Profit Organization and Management Liability Insurance

Notice: Except as otherwise provided in the policy, the policy shall only apply to claims first made against the insureds during the policy period and reported in writing to the insurer in accord with the provisions of the policy.

The Applicant Company, which is to be the entity named in Item 1. of the Declarations (the "Applicant"): *
Principal Address: *
Name and Title of officer designated to receive corespondence and notices from the Insurer:  *

Please provide the following information with respect to the Applicant: 

Purpose or description of operations:  *
Date of Incorporation:  *
 /  / 
Is the Applicant exempt from Federal income tax?  *
Has there been any dispute regarding the Applicant's tax exempt status?  *
Website address (if applicable):
Is the Applicant applying for insurance for any entity other than the Applicant?  *
If yes, please provide the following information for each: Name of entity, whether it is a non-profit or for profit, and type of operation or business.

´╗┐Financial Information: 

Please provide the following information for the past two fiscal years, separated by a slash: 

Fiscal year-ended:  *
Total Gross Revenue:  *
Net Revenue:  *
Total Assets:  *
Net Assets:  *
Based upon the Applicant's financial condition, has anyone questioned within the last three (3) years whether the Applicant will continue as a going concern? *

Please attach the Applicant's CPA-prepared financial statements or IRS Form 990 for the last two (2) fiscal years if any of the following apply to the Applicant for either of the last two (2) fiscal years:

  • Total gross revenues exceeded $2,000,000
  • Total assets exceeded $5,000,000
  • Either net revenues or net worth were negative
  • The answer to the previous question was "Yes" 
Upload File 1:
Upload File 2:

Employment Information: 

Please provide the following information for the Applicant and any Subsidiary for which coverage is requested. 

Number of full time employees:  *
Number of part time employees:  *
Does the Applicant employ a full-time Human Resource Manager?  *
Does the Applicant utilize an employee handbook?  *

Does the applicant distribute to all employees written policy statements regarding: 

Anti-discrimination? *
Anti-sexual harassment?  *

Please provide the following information regarding any Directors & Officers/Organization Liability  insurance currently maintained by the Applicant:

Insurer, Expiration Date, Limit, Deductible, and Premium:  *

Please provide the following information regarding any General Liability insurance currently maintained by the Applicant:

Insurer, Expiration Date, Limit, Deductible and Premium:  *

´╗┐Loss/Claims History: 

Has any Insurer cancelled or refused to renew any previous insurance, whether primary or excess, within the past 3 years?  *
Within the past 3 years, has any Claim been made against any proposed Insured which would have been within the scope of coverage afforded by the proposed Policy?  *

If yes, please attach a summary description listing each Claim and any Loss payments by any Insureds or Insurers: 

Upload a File:
Within the past 3 years, has any person or entity for whom this insurance is intended given notice under the provisions of any other previous or current similar primary or excess insurance policy of any facts or circumstances which may give rise to a Claim?  *

If yes, please attach complete details: 

Upload File:

Thank you for completing this form! We will be in touch with you shortly. 

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