Non Profit Art & Culture Product

Non Profit Art & Culture Product PDF Download

Non Profit Art & Culture Product

  • Arts & Culture Product Application

  • Please fill out the General Information section; along with the section(s) you are requesting coverage.
  • SECTION I. GENERAL INFORMATION

    (check all that apply)
  • Full-time employees:Part-time employees:Independent contractors:Volunteers: 
    If traveling only – skip to question 14.
  • sq. ft.
  • sq. ft.
  • sq. ft.
  • 23. Total annual gross revenues:
  • SECTION II. GENERAL LIABILITY

  • 37. Loss history for general liability for the past five years:
  • Date Loss:Type/Description:Incurred ($):Reserved ($):Open/closed: 
    Add a new row
    Please use the + button to the right to add additional Loss History.
  • Carrier:Policy Team:Limits ($):Premium ($):Open/closed: 
  • SECTION III. PROPERTY

  • 39. Limits desired and rating information
  • $
  • %
  • $
  • %
  • $
  • %
  • $
  • $
  • Inside ($)
  • Outside ($500 Standard Deductible)
  • Inside ($)
  • Outside ($500 Standard Deductible)
  • $
    (Coverage requires a maintenance contract for all refrigeration units)
  • ft.
  • ItemDescription (Year, Manufacturer & Model)Serial NumberLimit of Insurance ($) 
    Add a new row
    Please use the + button to the right to add additional items.
  • ($)
  • ItemDescription (Year, Manufacturer & Model)Largest ItemTotal of items ($) 
    Add a new row
    Please use the + button to the right to add additional items.
  • ($)
  • Date LossType/DescriptionIncurredReservedOpen/closed 
    Add a new row
    Please use the + button to the right to add additional items.
  • CarrierPolicy TermLimitsPremium 
    Add a new row
    Please use the + button to the right to add additional items.
  • SECTION IV. NON PROFIT DIRECTORS & OFFICERS AND EMPLOYMENT PRACTICES LIABILITY SECTION

    If “yes,” please complete the Non Profit Subsidiary Addendum (NPSADD).
  • 66. Name and title of individual designated to receive all notices on behalf of the Insured:
  • 67. Directors and officers liability Insurance carried:

  • 69. Please provide the following financial information for the last three years. (If organization in existence less than three years please provide budgeted revenue/expense statement for next three years.)

  • Applicant’s Warranty Statement: The undersigned represents to the best of his/her knowledge and belief the particulars and statements set forth are true and agree that those particulars and statements are material to the acceptance of the risk assumed by the Company. The undersigned further declares that any claim, incident or event taking place prior to the effective date of the insurance applied for which may render inaccurate, untrue, or incomplete any statement made will immediately be reported in writing to the applied for which may render inaccurate, untrue, or incomplete any statement made will immediately be reported in writing to the Company and the Company may withdraw or modify andy outstanding quotations and/or authorization or agreement to bind the insurance. The signing of the Application does not bind the undersigned to purchase the insurance, nor does the review of the Application bind the Company to issue a policy. It is understood the Company is relying on the Application in the event th Policy is issued. It is agreed that this Application, including any material submitted therewith, shall be the basis of the contract should a policy be issued, and may be attached dot and become part of the policy.

  • Virginia Notice: Statements in the application shall be deemed the insured’s representations. A statement made in the application or in any affidavit made before or after a loss under the policy will not be deemed material or invalidate coverage unless it is clearly proven that such statement was material to the risk when assumed and was untrue.

    Minnesota Notice: The clause “and/or authorization or agreement to bind the insurance.” is replaced with “Authorization or agreement to bind the insurance may be withdrawn or modified based on changes to the information contained in this application prior to the effective date of the insurance applied for that may render inaccurate, untrue or incomplete any statement made with a minimum of 10 days notice given to the insured prior to the effective date of cancellation when the contract has been in effect for less than 90 days or is being canceled for nonpayment of premium.

    Colorado Fraud Statement: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado division of insurance within the department of regulatory agencies.

    District of Columbia Fraud Statement: WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant.

    Florida Fraud Statement: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.

    Kentucky Fraud Statement: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime.

    Maine and Washington Fraud Statement: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits.

    New Jersey Fraud Statement: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties.

    New York Fraud Statement: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.

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

    Oklahoma Fraud Statement: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.

    Pennsylvania Fraud Statement: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.

    Tennessee and Virginia Fraud Statement: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.

    Fraud Statement (All Other States): Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

  • (President, Chairperson or Executive Director)
  • If the primary address of the location listed in item #1 is in the state of New York, Iowa, or Florida, the states of New York, Iowa, and require that we have the name and address of your (insured’s) authorized Agent or Broker.