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Directors and Officers (Not For Profit) Liability Premium Indication

Florida Organizatons only please

Name of Organization
  
Mailing Address
  
     
City County State Zip
  
Business Phone Fax
Email

The officer designated as agent of the Organization and all of the Insureds to receive any and all notices from the Insurer or an authorized representative concerning this insurance:
Name: Title:

Describe the Organization’s purpose and the nature of operation(s):

Date organized
Tax status: Taxable or Tax Exempt under of IRC Sec. 501(c)

Number of Employees
Annual Salary/Wages Expense
Total Assets
$
$
Number of Volunteers
Revenue
Total Liabilities
$
$

Please provide the following information on all Subsidiaries. (a) Name; (b) Date of acquisition/creation; (c) Percent of control; (d) Nature of operation; (e) Operated for profit or non-profit; and (f) Name of parent organization. Please attach the most recent annual report or annual audit/examination or internal financial statement for each Subsidiary
If "None", please indicate: None
COVERAGE IS NOT AUTOMATICALLY PROVIDED FOR ALL SUBSIDIARIES. TERMS AND CONDITIONS OF COVERAGE FOR SUBSIDIARIES ARE DETAILED IN SECTION III D.

Have there been any changes in senior management (Executive Director, President, Executive Vice President, etc.) for reasons other than death, retirement at the normal retirement age or term limitations?
No Yes. If "Yes", please explain:
 

What was the approximate turnover rate for employees in the last twelve months? %
Did the turnover rate of employees exceed historical levels of the past five years?
No Yes. If "Yes", please explain:
 

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 three years?
No Yes. If "Yes", please explain:
 

Does the Organization or any proposed insured perform any of the following:
Promote, sponsor or provide any form of insurance to members or non-members? Yes No
Take any disciplinary action or recommend disciplinary action as a result of peer review or standard setting activities? Yes No
Engage in any labor negotiations? Yes No
Provide any other professional services? Yes No
Engage in any business transactions with businesses which are controlled by any proposed Insured Persons? Yes No
Engage in any form of research, development or experimentation? Yes No
If "Yes", for any of the above, please provide details.

Does the Organization or any proposed Insured have knowledge of any Federal, State or local legal proceedings, investigations or claims against the Organization and/or any proposed Insured during the past five years? IT IS UNDERSTOOD AND AGREED THAT ANY CLAIM ARISING THEREFROM SHALL BE EXCLUDED UNDER THE PROPOSED COVERAGE.
No Yes. If "Yes", please explain:
 

Is the officer designated as agent of the Organization 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? IT IS UNDERSTOOD AND AGREED THAT IF KNOWLEDGE OR ANY SUCH FACT, CIRCUMSTANCE OR SITUATION EXISTS, ANY CLAIM SUBSEQUENTLY ARISING THEREFROM SHALL BE EXCLUDED UNDER THE PROPOSED COVERAGE.
No Yes. If "Yes", please provide details:
 

Current Executive Protection and Employment Practices Liability Insurance, Directors’ & Officers’ Liability Insurance or similar coverage (answer each item):
a. Carrier
b. Limit
c. Retention
d. Policy Expiration
e. Premium

Has any carrier refused, canceled or non-renewed similar coverage?
No Yes. If "Yes", please provide details:
 

Have any notices been provided to any previous carrier?
No Yes. If "Yes", please provide details:
 

Any person who, with intent to defraud or knowing that he is fascilitating a fraud against the insurer, submits an application or files a claim containing false or deceptive statement is guilty of insurance fraud.

 

 

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