top of page
Comprehensive
Insurance Coverage
For Today's Risks
Get A Quote
Access My Docs
Contact Us
Report A Claim
Niche Programs
Insurance for Small Businesses
Insurance for Housing Programs
Insurance for Nonprofits & Social Srvs
Insurance for the Arts
Health Insurance
Latest News!
Directors and Officers Liability Quote
First Name
Email
Last Name
Phone
Address
Web Address
Total Annual Revenue (if >$2 Million Recent 12-Month Finanicial Statement required)
Existence Since
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?
Yes
No
Does organization have tax exempt status by the I.R.S.?
Yes
No
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?
Yes
No
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?
Yes
No
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.
Submit
Thanks for submitting!
bottom of page