16. Complete the following for the past two fiscal years:
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Fiscal year-ended |
Total Gross Revenue |
Net Revenue |
Total Assets |
Net Assets |
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17. Based upon the organization's financial condition, has there been any
question as to whether it will continue as a going concern?
Note: Financial statements or IRS
forms 990 are required for the past two fiscal years if any of the
following are true: Total Gross Revenue is greater than $2,000,000; Assets
are greater than $5,000,000; Negative Net Revenue or Negative Net Assets
are reported; or the answer to #17 is "yes". (applicable to
previous two questions)
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18. Has the Organization reported any
loss or potential loss to its current or any prior Directors &
Officers Liability insurer? |
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19. Has any claim been made against the
Organization, its Directors, Officers or other personnel for any error or
omission in the performance of its/his/her duties? |
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20. Is the Organization, its Directors,
Officers or other personnel cognizant of any fact, circumstance or
situation which may reasonably be expected to give rise to a claim within
the scope of the Directors & Officers or Organization Liability
policy? |
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21. IF ANY ANSWER TO QUESTIONS #18, 19 OR 20 IS "YES", PLEASE DESCRIBE
THE CLAIM OR CIRCUMSTANCE, INCLUDING DATE, CLAIMANT, BASIS OF CLAIM,
STATUS, ANY SUMS SOUGHT AND/OR DEFENSE COSTS AND SETTLEMENTS
INCURRED.
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ADDITIONAL INFORMATION REQUIRED
Please e-mail or fax copies of the following information for
underwriting and rating purposes:
1. Claims history as noted above
2. CPA-prepared financial statements for the past two fiscal years
or 990 tax forms, if required #22 and 23. |