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Insurance for Small Businesses
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Directors and Officers Liability Quote
Total Annual Revenue (if >$2 Million Recent 12-Month Finanicial Statement required)
If Less than 3 years, estimated annual revenue This Year:
Estimated annual revenue Next Year
Estimated annual revenue Third Year
Total Fund Balance (Total Assets minus Total Liabilities)
Number Full Time Employees
Number of Temp/Seasonal Employees
Number Part Time Employees
Number of Volunteers
How many of the above employees/volunteers are located outside the U.S.?
Does organization have an anti-harassment and anti-discrimation policy?
Does organization have tax exempt status by the I.R.S.?
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 Insuance in the capacity of Director, Officer, Trustee, Employee or Voluteer of any entity proposed for Insurance?
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?
By Checking this box you attest all information is correct to your knowledge. Fraud Notice: Any person knowingly persents a false or fraudulent claim for payment of a loss or benefit or knowingly persents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
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