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Directors & Officers Quote Form


Fill out the following form as completely as possible. Once you have completed the form, click the Submit button to send your information. Your request will be handled promptly.

Contact Information
Company Name
Required
Internet Address
Required
First Name
Required
Last Name
Required
Title
Required
E-Mail Address
Required
Federal ID
Required
Primary Phone Number
Required
Alternate Phone Number
Optional
Street
Required
City
Required
State
Required
ZIP / Postal Code
Required
General Information
Business Type
Required
Limits of Liability
Required
Do you currently have insurance?
Required
If "Yes", what type?
Optional


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Expiration Date
Optional
/ /
Year Business Established
Required
Detail description of operations
Required
State of Incorporation
Required
# of Directors
Required
Directors' Name & Position
Required
# of Officers
Required
Officers' Name & Position
Required
# of Chapters
Required
# of Members
Required
Do you have a tax-exempt status under the U.S. Internal Revenue Code?
Required
Do you publish any magazines, periodicals or newsletters?
Required
If "Yes", please explain
Optional
Are you involved in product research, product development, testing and/or certification?
Required
If "Yes", please explain
Optional
Do you set standards for the qualification and performance and/or certify your members?
Required
If "Yes", please explain
Optional
Do you engage in any disciplinary actions as a result of peer review activities?
Required
If "Yes", please explain
Optional
Do you administer or sponsor any insurance programs for your members?
Required
If "Yes", please explain
Optional
Financial Information
Previous Year
Total Assets
Required
Net Assets/Fund Balance
Required
Annual Revenue
Required
Change in Net Assets (Excess/Deficit)
Required
Current Year
Total Assets
Required
Net Assets/Fund Balance
Required
Annual Revenue
Required
Change in net Assets (Excess/Deficit)
Required
Please upload the most recent annual financial audit or 990 form.
Required
Directors & Officers
Directors and Officers Liability Insurance has been continuously in force since
Required
Within the last 5 years, has any claim or suit been made against a Director, Officer, Employee, or Volunteer?
Required
Are you aware of any fact, circumstance or situation which may result in a claim?
Required
Do you provide services for persons under the age of 18?
Required
Employee Practices - Optional
# of Employees 1 Year Ago
Full Time
Optional
Part Time
Optional
Temporary
Optional
Leased
Optional
Non U.S. based employees/volunteers
Optional
Total Sum
Optional
# of Employees Currently
Full Time
Optional
Part Time
Optional
Temporary
Optional
Leased
Optional
Total Sum
Optional
How many employees have been terminated in the past 12 months?
Optional
How many employees have been demoted in the past 12 months?
Optional
How many employees will be terminated in the next 12 months?
Optional
How many employees will be demoted in the next 12 months?
Optional
Do you have an employment handbook?
Optional
Do you use an employment application for every potential employee?
Optional
Do you have an "At Will" provision in the employment application or handbook?
Optional
Have you implemented an anti-sexual harassment policy?
Optional
Do you use outside employment counsel for employment advise?
Optional
Additional Coverages
Is Workplace Violence coverage desired?
Optional
Is Internet Liability desired?
Optional
Additional Information
How did you hear about us?
Required
Submission Validation
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Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

Per the terms of our online privacy policy we will not resell your information to any third-party.
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