Non Profit Art & Culture Product

Non Profit Art & Culture Product PDF Download

Non Profit Art & Culture Product

Arts & Culture Product Application
Type of coverage being requested:*
- General Liability
- Property/Inland Marine
- Nonprofit D&O
Please fill out the General Information section; along with the section(s) you are requesting coverage.
SECTION I. GENERAL INFORMATION
1. Name of applicant:*
Prefix First Last Suffix
2. Does the organization have a tax exempt status as defined by the I.R.S.?*
- Yes
- No
3. Mailing Address:*
Street Address Address Line 2 City State ZIP Code
4. Location Address:*
Street Address Address Line 2 City State ZIP Code
5. Website Address:*
Email Address:*
6. Number of years in operation?*
7. Does the organization have a prior, existing or pending bankruptcy in the last five years?*
- Yes
- No
8. Purpose of organization:*
9. Activities of the organization?:*
- Music/Instrumental
- Ballet
- Cheerleading/Aerobics
- Community service
- Promoters
- Music/Vocal
- Comedy troupes
- Gymnastics
- Fundraising
- Other
- Theatre/Plays
- Choir
- Martial arts
- Third Choice
- Booking agent/Event planner
- Theatre/Opera
- Orchestra
- Camps
(check all that apply)
(Attach copy of brochure, website pages and flyer to this application)
Max. file size: 300 MB.
10. Total number of performers:*
Full-time employees: Part-time employees: Independent contractors: Volunteers:
11. Building interest?*
- Owner:
- Tenant:
- Traveling only:
If traveling only – skip to question 14.
12. Total of building:*
sq. ft.
Area occupied by the organization:*
sq. ft.
Area leased to others:*
sq. ft.
13. Do you lease premises?*
- Yes
- No
If “yes,” what purpose?
14. Is all electrical wiring connected to functional and operational circuit breakers?*
- Yes
- No
15. Electrical systems do not have aluminum or knob and tube wiring?*
- Yes
- No
16. Are there functioning smoke or heat detectors used in all public areas?*
- Yes
- No
17. Are all public areas equipped with lighted exit signs?*
- Yes
- No
18. Is a secondary means of egress provided for each floor (including basement) having public access?*
- Yes
- No
19. What is the average ticket price per performance?*
20. Indicate the number of performances planned during policy term:*
21. Average attendees per performance:*
22. Maximum attendance at any one performance:*
23. Total annual gross revenues:
Admissions:*
Alcoholic beverages:*
Food and non-alcoholic beverages:*
Donations:*
Public funding:*
Rent from others for use of facilities:*
Products sold: (please attach a list of products sold):*
Other sources:*
Total annual gross revenue:*
SECTION II. GENERAL LIABILITY
24. Are animals used for any performances?*
- Yes
- No
If “yes,” what type(s)?
25. Do you provide permanent or temporary housing for staff, performers, etc.?*
- Yes
- No
26. Do you conduct any overnight tours?*
- Yes
- No
If “yes,” will any member be under the age of 21?*
- Yes
- No
27. Do you rent or lease your premises to others?*
- Yes
- No
28. Any construction of scenery, backdrops or stages over three stories in height or use of bulldozers, backhoes, excavators or cranes?*
- Yes
- No
29. Do you utilize independent contractors?*
- Yes
- No
If “yes,” do you obtain certificates of insurance from independent contractors?*
- Yes
- No
30. Do all performances end before 12:00 a.m.?*
- Yes
- No
31. Any performances with aerial acts over the crowd?*
- Yes
- No
If “yes,” do you obtain certificates of insurance from independent contractors?*
- Yes
- No
32. Any alleged incidents regarding molestation or abuse?*
- Yes
- No
If “yes,” please describe:
33. Are there any special effects that include pyrotechnics/fireworks?*
- Yes
- No
34. Any international travel, overnight camps or schools?*
- Yes
- No
35. Will any performances take place in a vacant building?*
- Yes
- No
36. Within the past five years, has the general liability coverage been cancelled or non–renewed?*
- Yes
- No
If “yes,” explain:
37. Loss history for general liability for the past five years:
- if none, check here
Please use the + button to the right to add additional Loss History.*
Date Loss: Type/Description: Incurred ($): Reserved ($): Open/closed:

Please use the + button to the right to add additional Loss History.
38. List expiring general liability carrier, term, limits and premium:*
Carrier: Policy Team: Limits ($): Premium ($): Open/closed:
SECTION III. PROPERTY
39. Limits desired and rating information
Building Construction*
- Frame
- Noncombustible
- Fire resistive
- Joisted masonry
- Masonry NC
Protection Class*
- 1-6
- 7-8
- 9-10
Deductible*
- $1,000
- $2,500
- $5,000
Cause of Loss*
- Basic
- Special/excluding theft
- Special (requires a (central station burglar alarm)
Building Limit:*
$
Coinsurance (80% minimum):
%
*
- ACV
- RC
Improvements and Betterments Limit:*
$
Coinsurance (80% minimum):
%
*
- ACV
- RC
Business Personal Property Limit:*
$
Coinsurance (80% minimum):
%
*
- ACV
- RC
Business Income Limit:*
$
Coinsurance:
- 50%
- 80%
- 100%
- With Extra Expense
Monthly Limit of Indemnity
- 1/3
- 1-4
- 1-6
- With Extra Expense
- Value Plus Endorsement (Requires a Central Station Burglar Alarm)
Employee Dishonesty:
$
# of Employees:
Money &•Securities:
Inside ($)
Outside ($500 Standard Deductible)
Outside ($500 Standard Deductible)
Burglary & Robbery:
Inside ($)
Outside ($500 Standard Deductible)
Outside ($500 Standard Deductible)
Outdoor Signs:
$
(Coverage requires a maintenance contract for all refrigeration units)
- Equipment Breakdown:
(Coverage requires a maintenance contract for all refrigeration units)
40. Has any officer or board member of this organization ever been convicted of the felony of arson?*
- Yes
- No
41. Are there any tax liens on any property?*
- Yes
- No
42. Any on premise welding operations?*
- Yes
- No
43. Cooking Supplement - If no cooking, check here
a. Is there a cleaning contract in force with an outside firm?*
- Yes
- No
b. Describe cooking equipment used:*
- Grills
- Charcoal grill
- Open flame
- Barbeque pit/Smoke
- Oven
- Type or brand
- Deep fat fryers
Distance from building:*
ft.
c. Type of extinguishing system:*
- Wet
- Dry
44. Type of plumbing?
- PVC/Plastic
- Copper
- Iron
- Lead
- Galvanized
- Other
45. Type of roof?*
- Flat
- Wood shake
- Shingle
- Metal
- Tile
- Slate
- Other
46. Roof updated:*
MM slash DD slash YYYY
Electrical updated:*
MM slash DD slash YYYY
Plumbing updated:*
MM slash DD slash YYYY
Heating updated:*
MM slash DD slash YYYY
47. Age of building:*
48. Are there vacancies in the building?*
- Yes
- No
49. Burglar alarm:*
- Local
- Central station burglar alarm
50. Fire protection:*
- Local
- Central station fire alarm
- Local fire alarm
- Annually serviced fire extinguisher(s)
51. Within the past five years, has property coverage been cancelled or non-renewed?*
- Yes
- No
If “yes,” explain:
52. Inland marine:*
- Theater property
- Musical instruments
Schedule of property and equipment for which coverage is requested:*
Item Description (Year, Manufacturer & Model) Serial Number Limit of Insurance ($)

Please use the + button to the right to add additional items.
Total Blanket:*
($)
Blanket coverage description (if requesting blanket coverage) - individual items under $2,500 in value:*
Item Description (Year, Manufacturer & Model) Largest Item Total of items ($)

Please use the + button to the right to add additional items.
Total Blanket:*
($)
53. Deductible:*
- $500
- $1,000
- $2,500
- $5,000
- $10,000
54. Does the insured lease, loan or rent covered property or equipment to others?*
- Yes
- No
55. Is any insured property or equipment on this schedule left unlocked and/or unsecured when not in use?*
- Yes
- No
56. Are any objects unique or difficult to replace?*
- Yes
- No
57. Do any objects have value beyond their apparent worth due to being rare or collectible?*
- Yes
- No
58. Is all insured’s covered property or equipment brought back to their place of business at the end of each day?*
- Yes
- No
a. If so, is the place of storage protected by a central station alarm system?*
- Yes
- No
59. Loss history for property/inland marine for past three years:*
Date Loss Type/Description Incurred Reserved Open/closed

Please use the + button to the right to add additional items.
- If none, check here.
60. List expiring property carrier, term, limits and premium:*
Carrier Policy Term Limits Premium

Please use the + button to the right to add additional items.
SECTION IV. NON PROFIT DIRECTORS & OFFICERS AND EMPLOYMENT PRACTICES LIABILITY SECTION
61. Does the organization administer or sponsor any insurance programs?*
- Yes
- No
62. Is the organization involved in any accreditation or standard setting activities?*
- Yes
- No
63. Is the organization involved in any labor/union negotiations or collective bargaining activities?*
- Yes
- No
64. Number of chapters:*
If there are chapters, is coverage requested for them under this policy?
- Yes
- No
65. Does the applicant have any subsidiaries requiring coverage?*
- Yes
- No
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:
Title:*
Phone Number:*
67. Directors and officers liability Insurance carried:
68. Does the organization currently carry general liability Insurance?*
- Yes
- No
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.)
70. Is any person proposed for this insurance aware of any fact, circumstance or situation, which may result in a claim against the organization or any of its directors, trustees, officers, employees or volunteers? (If “yes,” please forward a completed USLI supplemental claims application)*
- Yes
- No
71. Within the last 5 years, has any inquiry, complaint, notice of hearing, claim or suit been made (including, but not limited to, Equal Employment Opportunity Commission, State Human Rights Boards, Municipal, State or Federal Regulatory Authorities), against the organization, or any person proposed for insurance in the capacity of director, officer, trustee, employee or volunteer of the organization? (If “yes,” please forward a completed USLI supplemental claims application)*
- Yes
- No
72. Does each pension plan use an outside investment manager? (If “no,” Fiduciary will not be offered)*
- Yes
- No
73. Does each plan subject to ERISA comply with all applicable requirements of ERISA and the Internal Revenue Code of 1982, as amended (the “Code”) including eligibility, participation, vesting, fiduciary responsibility and funding standards?*
- Yes
- No
(If no, please attach details)
74. In the past two years has there been or is there now under consideration any material changes to a plan or termination/consolidation of a plan?*
- Yes
- No
(If Yes, please attach details)
75. Has there been or is there now pending any claims(s) against any proposed insured arising out of any Plan?*
- Yes
- No
(If Yes, please attach details)
76. Does any proposed Insured have knowledge or information of any act, error or omission which might give rise to a claim under the proposed Fiduciary Liability coverage?*
- Yes
- No
(If Yes, please attach details)
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.
Applicant’s signature:*
(President, Chairperson or Executive Director)
Title:*
Date:*
MM slash DD slash YYYY
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.
Producer Name:*
Retail Agency Name:*
Signature*
Address*
Street Address Address Line 2 City State ZIP Code

Date Loss:	Type/Description:	Incurred ($):	Reserved ($):	Open/closed:

Item	Description (Year, Manufacturer & Model)	Serial Number	Limit of Insurance ($)

Item	Description (Year, Manufacturer & Model)	Largest Item	Total of items ($)

Date Loss	Type/Description	Incurred	Reserved	Open/closed

Carrier	Policy Term	Limits	Premium

Non Profit Art & Culture Product

Non Profit Art & Culture Product

Arts & Culture Product Application

SECTION I. GENERAL INFORMATION

SECTION II. GENERAL LIABILITY

SECTION III. PROPERTY

SECTION IV. NON PROFIT DIRECTORS & OFFICERS AND EMPLOYMENT PRACTICES LIABILITY SECTION

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.)