Organization name:

Contact name:

Mailing address:

City: State: Zip:

Phone number: Fax number:

*E-mail:

* Required Information!

Web site:

Describe your services:

Does your organization have a 501(c)3 filing?   Yes No

Year Organization Established:

Current Insurance Carrier?

What type of insurance coverage's are you requesting?

General Liability

Professional Liability

Improper Sexual Conduct Liability

Employee Dishonesty, Forgery, Burglary

Special Events Liability

Umbrella Liability

Property

Building

Business Personal Property

Extra Expense/Income Protection

Business Auto

Non Owned & Hired Auto Liability

Directors & Officers Liability

Employment Practice Liability

Volunteer Accident/Health Policy

Workers Compensation

Directors and Officers Liability section:

Operating:    Local  State  Regional  National  Int'l

Do you have any subsidiary corporations?   Yes No

Involved with product testing, certification, or professional
standard testing?   Yes No

Revenues: Expenses: Assets:

Liabilities: Fund Balance:

Number of employees -    Full time:   Part time:


For Liability Quotes, complete the following section:

Estimated number of clients:

Percentage of handicapped clients:
  
Emotional   Developmental   Physical

Estimated number of employees in a position with clients:

Do volunteers work directly with clients?   Yes No

Any closed door, one-on-one counseling with clients?   Yes No

Are clients in your care overnight?   Yes No

Limit of coverage requested?

Crime / Employee Dishonesty

Is check writer also authorized to make withdrawals?   Yes No

Is a countersignature required of checks?   Yes No

Limit of coverage requested?

Property - Building, Contents and Computer Coverage

How many locations does the organization occupy?

How many locations does the organization own?

Building limit of coverage required? (if applicable)

Contents limit of coverage required? (if applicable)

Business income limit required? (if applicable)

Extra expense? (if applicable)

Computer hardware limit required? (if applicable)

Computer software limit required? (if applicable)

Construction of building: Number of stories:

Year built: Total area:

Does the building have a burglar alarm?   Yes No      

Fire alarm?   Yes No

Emergency sprinkler system?   Yes No

For Business Automobile Quotes, complete the following:

Include all owned, leased and rented vehicles:

For Workers' Compensation Quotes complete the following:

Federal Employer ID number: