Non-Profit Directors & Officers  

Basic Information

1. Name of Organization:

 

2. Principal Address:

  

3. Telephone:

4. Fax:

5. E-mail:

6. Name of individual designated to receive notices regarding this coverage:

7. Date Incorporated:
Entity Details

8. Does the Organization now have a tax-exempt status with the IRS?

9. Has there been any dispute as to the Organization's tax-exempt status?

If yes, please explain:

10. Statement of purpose or description of operations::

11. Number of employees (stated in full-time equivalents):

12. Does the employ a full-time Human Resource Manager?

If yes, please give name:

13. Does the Organization utilize an employee handbook?  


 


14. Does the Organization have any subsidiaries or affiliates over which it exercises administrative and/or fiscal control?    If yes, list each subsidiary or affiliate below:


Please provide information on current Directors & Officers/Organization Liability and General Liability Insurance:

Name of subsidiary/affiliate

Non-profit/For-profit

Relationship to Organization

 

 

 

15. Please provide information on current Directors & Officers/Organization Liability and General Liability Insurance:

Insurer

Expiration Date

Limit

Deductible

Premium

D&O:

GL:


16. Complete the following for the past two fiscal years:

Fiscal year-ended

Total Gross Revenue

Net Revenue

Total Assets

Net Assets


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)

 
18. Has the Organization reported any loss or potential loss to its current or any prior Directors & Officers Liability insurer?

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?

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?


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. 

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.

This document is a non-binding indication question sheet and is subject to receipt of a fully completed application and supporting documents prior to firm quotations being rendered by the company.  Upon review of these documents, the company reserves the right to change the terms indicated via this questionnaire or decline to render terms for this coverage.