Non-Profit Organization Quote Form

Fill out the following form as completely as possible. Once you have completed the form, click the Submit button to send your information. Your request will be handled promptly.

Contact Information

Company Name *

Internet Address *

First Name *

Last Name *

Title *

E-Mail Address *

Federal ID *

Primary Phone Number *

Alternate Phone Number

Street *

City *

State *

ZIP / Postal Code *

General Information

Business Type *

Limits of Liability *

Do you currently have insurance? *

If "Yes", what type? *

Hold down the Ctrl Key to make multiple selections.

Expiration Date

Year Business Established *

Detail description of operations *

State of Incorporation *

# of Directors *

Directors' Name & Position *

# of Officers *

Officers' Name & Position *

# of Chapters *

# of Members *

Do you have a tax-exempt status under the U.S. Internal Revenue Code? *

Do you publish any magazines, periodicals or newsletters? *

If "Yes", please explain

Are you involved in product research, product development, testing and/or certification? *

If "Yes", please explain

Do you set standards for the qualification and performance and/or certify your members? *

If "Yes", please explain

Do you engage in any disciplinary actions as a result of peer review activities? *

If "Yes", please explain

Do you administer or sponsor any insurance programs for your members? *

If "Yes", please explain

Financial Information

Previous Year

Total Assets *

Net Assets/Fund Balance *

Annual Revenue *

Change in Net Assets (Excess/Deficit) *

Current Year

Total Assets *

Net Assets/Fund Balance *

Annual Revenue *

Change in net Assets (Excess/Deficit) *

Please upload the most recent annual financial audit or 990 form. *

Directors & Officers

Directors and Officers Liability Insurance has been continuously in force since *

Within the last 5 years, has any claim or suit been made against a Director, Officer, Employee, or Volunteer? *

Are you aware of any fact, circumstance or situation which may result in a claim? *

Do you provide services for persons under the age of 18? *

Employment Practices Liability

Employment Practices Liability Insurance has been continuously in force since *

# of Employees 1 Year Ago

Full Time *

Part Time *

Temporary *

Leased *

Non U.S. based employees/volunteers *

Total Sum *

# of Employees Currently

Full Time *

Part Time *

Temporary *

Leased *

Non U.S. based employees/volunteers *

Total Sum *

How many employees have been terminated in the past 12 months? *

How many employees have been demoted in the past 12 months? *

How many employees will be terminated in the next 12 months? *

How many employees will be demoted in the next 12 months? *

Do you have an employement handbook? *

Do you use an employment application for every potential employee? *

Do you have an "At Will" provision in the employment application or handbook? *

Have you implemented an anti-sexual harassment policy? *

Do you use outside employment counsel for employment advise? *

Optional Coverages

Is Workplace Violence coverage desired?

Is Internet Liability desired?

Additional Information

How did you hear about us? *

Submission Validation

Required

Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

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