| Name |
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| Contact Information |
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| Address |
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| Applicant’s name |
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| Location address |
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| City |
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| State |
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| Zip code |
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| Mailing address |
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| City |
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| State |
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| Zip code |
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| Website address |
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| E-mail address of primary contact |
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| Description of operations |
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| Total annual revenue |
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| If less than three years in operation |
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| Annual Revenue: this year |
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| Annual Revenue: next year |
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| Annual Revenue: third year |
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| Total fund balance (total assets minus total liabilities) |
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| Full-time employees |
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| Part-time |
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| Temporary/Seasonal |
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| Volunteers |
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| Does the organization perform any operations located outside the U.S.? |
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| In existence since |
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| UNDERWRITING INFORMATION |
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| 1. Does the organization have an anti-harassment and anti-discrimination policy? (Y or N) |
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| 2. Does the organization have tax exempt status by the IRS? (Y or N) |
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| 3. Does the organization have general liability insurance? (Y or N) |
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| 4. Expiring D&O information |
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| a. Carrier: |
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| b. Limits: |
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| c. Retention: |
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| d. Premium: |
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| 5. Is any entity proposed for insurance involved in any of the following? (Attach a statement of details for all “yes” answers to the following) |
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| a. Research, development or testing? (Y or N) |
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| b. Certification, accreditation or standard-setting? (Y or N) |
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| c. Disciplinary actions as a result of peer review activities? (Y or N) |
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| d. Administration or sponsorship of any insurance programs? (Y or N) |
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| e. Labor/union negotiations or collective bargaining? (Y or N) |
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| 6. Does the applicant have any chapters or subsidiaries requiring coverage? (Y or N) |
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| 7. Has any entity proposed for insurance closed, downsized, laid off, reduced staff, sold, merged with or acquired any company in the past 12 months or anticipates doing so in the next 12 months? (Y or N) |
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| 8. Has the applicant or any person proposed for coverage (whether or not in the service of applicant) been the subject of or been involved directly or indirectly in any civil, criminal, regulatory, legislative or administrative proceeding(s)? (Y or N) |
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| 9. |
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| a. Within the last five years, has any inquiry, complaint, notice of hearing, claim or suit been made against any entity proposed for insurance, or any person proposed for insurance in the capacity of director, officer, trustee, employee or volunteer of any entity proposed for insurance? (Y or N) |
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| b. Is any person(s) proposed for this insurance aware of any fact, circumstance or situation which may result in a claim against any entity proposed for insurance or any of its directors, officers, trustees, employees or volunteers? (Y or N) |
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| 10. Has any policy for directors and officers or employment practices liability ever been cancelled or non-renewed? (Y or N) |
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| FIDUCIARY (All questions must be answered in order for fiduciary liability coverage to be bound) |
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| 1. Does each pension plan use an outside investment manager? (Y or N) |
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| 2. Does each plan subject to ERISA comply with all applicable requirements of ERISA and the Internal Revenue Code of 1982, as amended (the “Code”) including: eligibility, participation, vesting, fiduciary responsibility and funding standards? (Y or N) |
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| 3. In the past two years has there been or is there now under consideration any material changes to a plan or termination/consolidation of a plan? (Y or N) |
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| 4. Has there been or is there now pending any claim(s) against any proposed insured arising out of any plan? (Y or N) |
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| 5. Does any proposed insured have knowledge or information of any act, error or omission which might give rise to a claim under the proposed fiduciary liability coverage? (Y or N) |
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| Applicant’s mailing address |
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| City |
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| State |
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| Zip |
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