Organization Name
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Mailing Address
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Date of Incorporation
*
Please enter Month/Day/Year.
MM
DD
YYYY
Tax ID Number
*
Contact Person
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First Name
Last Name
Phone
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(###)
###
####
Email
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Classes - Acceptable
Select the Organization's nature of operations
Classes - Refer to Underwriters
Select the Organization's nature of operation below (if any apply):
Please provide a complete description of your operations and events
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Does the Organization have any for-profit subsidiaries?
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If “Yes”, Please submit current financial statements for each of the for profit subsidiaries as an attachment to this
Proposal Form.
Is the Organization or any of its Subsidiaries involved in or presently considering any merger, consolidation, acquisition, divestment or sale of a portion of its business or has a similar transaction been considered or completed within the last twelve months?
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If “Yes”, Please provide a description of the transaction and submit projected financial statements for the posttransaction
organization.
Does the Organization or any proposed Insured perform, or are they involved in, any of the following:
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Number of full time compensated employees (over 30 hours per week for 12 months)
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Does the Organization take any disciplinary action or recommend disciplinary action as a result of credentials certification, accreditation, licensing, peer review or standard setting activities?
*
Has the Organization been in operation for fewer than 12 months?
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If “Yes”, Please provide a description of the Organization’s business plan and submit the Organization’s projected
budget for the next twelve months.
Number of part time compensated employees (under 30 hours a week or less than 12 months)
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Number of volunteers
*
Is the organization a not-for-profit entity?
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Is the insured a government entity or organization?
Is this entity the headquarters or main office of a state or national association/organization?
Annual Salary / Wages Expense:
Total organization’s assets on the financial statement
*
Total organization’s liabilities on the financial statement
*
If more than $5 million for any one category, please submit current financial statement.
Does the organization currently have D&O coverage in force?
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If yes, please provide Insurance Company Name:
If yes, please provide Limit of Insurance:
If yes, please provide total premium:
If yes, please provide Retention or Deductible:
If yes, please provide Expiration Date:
Desired Effective / Start Date
MM
DD
YYYY
Have there been during the last five years, or are there now pending, any civil, criminal, administrative or arbitration proceedings (including any proceeding initiated before the Equal Employment Opportunity Commission) brought against the Organization, its Subsidiaries, or any person proposed for this insurance in their capacity as either Director, Officer, Trustee, employee, volunteer, or staff member of the Organization or its Subsidiaries?
*
If "Yes", Please answer a. and b.
a. Have there been more than four such proceedings against the Organization or any proposed Insured during the past five years?
b. For each proceeding, please provide the dollar amount of loss, the date the proceeding was filed, and whether the proceeding is open or closed:
Proceeding/Claim 1: Total loss paid including Costs of Defense, Judgments, and/or Settlements:
Date the proceeding was filed:
Please provide the name of the claimant and a description of the allegations:
Status:
Proceeding/Claim 2: Total loss paid including Costs of Defense, Judgments, and/or Settlements:
Date the proceeding was filed:
Please provide the name of the claimant and a description of the allegations:
Status:
Proceeding/Claim 3: Total loss paid including Costs of Defense, Judgments, and/or Settlements:
Date the proceeding was filed:
Please provide the name of the claimant and a description of the allegations:
Status:
Proceeding/Claim 4: Total loss paid including Costs of Defense, Judgments, and/or Settlements:
Date the proceeding was filed:
Please provide the name of the claimant and a description of the allegations:
Status:
IT IS AGREED THAT ANY CLAIM ARISING FROM ANY PRIOR OR PENDING PROCEEDING IS EXCLUDED UNDER THE PROPOSED COVERAGE.
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Is the undersigned or any proposed Insured aware of any fact, circumstance or situation involving the Organization
or its Subsidiaries or any proposed Insured which he or she has reason to believe might result in a future Claim?
If “Yes”, Please provide a description of the fact, circumstance, and/or situation below:
How did you hear about me and my programs?
*
