Non Profit D&O Package Supplement Non Profit D&O Package Claim Examples PDF Download Non Profit D&O Package Supplement PDF Download Non Profit D&O Package Supplement Non Profit Premises Preferred Product NON PROFIT PREMISES PREFERRED PRODUCT SUPPLEMENTAL APPLICATION All questions must be answered and application must be signed by applicant. Please submit with a completed Acord 125 Application. SECTION I. General Information:1. Name of Organization;* 2. Mailing address:* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Please Check if Location is Same as Mailing Address. Location Address is Same as Mailing Address Please Check if Location is Same as Mailing Address.Location Address: Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code 4. Description of operation/services offered:*5. Web site address:* 6. E-mail address:* 7. Does the organization have tax exempt status as defined by the I.R.S.?* Yes No SECTION II. Premise Preferred8. Are revenues greater than $10,000,000?* Yes No 9. Please provide the square footage of the applicant’s premises:*SQ FT.10. Does the applicant have an international exposure?* Yes No If “Yes,” please provide details:11. Does the applicant have any of the following exposures?* Gymnasium Swimming Pool Soup Kitchen Adoption Childcare Habitational Playcenter Food Bank Abortion Clinic Thrift Store 12. Does the applicant have a stable or farm exposure?* Yes No 13. Does applicant provide Web and/or software development or programming services?* Yes No 14. Are there functioning smoke detectors on the premises?* Yes No 15. Does the risk contain aluminum wiring?* Yes No 16. Does the risk have 100% of the wiring on functioning circuit breakers? Important Note: Coverage is limited to premises liability at the location address(es) scheduled in our policy, subject to the terms and conditions of our policy. The products-completed operations hazard is not insured.* Yes No SECTION III. NON PROFIT DIRECTORS & OFFICERS AND EMPLOYMENT PRACTICES LIABILITY (if eligible):17. Is the organization involved in product research, development, testing and/or certification?* Yes No 18. Does the organization engage in any disciplinary actions as a result of peer review activities?* Yes No 19. Does the organization administer or sponsor any insurance programs?* Yes No 20. Is the organization involved in any accreditation or standard setting activities?* Yes No 21. Is the organization involved in any labor/union negotiations or collective bargaining activities?* Yes No 22. Total number of employees:*Full Time:Part Time:Volunteers:Seasonal:23. Number of members:*Number of chapters:*If there are chapters, is coverage requested for them under this policy?* Yes No 24. Does the applicant have any subsidiaries requiring coverage?* Yes No If “Yes,” please complete the Non Profit Subsidiary Addendum (NPSADD). 25. Name and title of individual designated to receive all notices on behalf of the insured:* Prefix First Last Suffix Title:* Phone number:*26. Directors and officers liability insurance carried:*Insurer:Limits of Liability:Premium:Retention:Policy Period: Please use the + button to the right to add additional.27. Does the organization currently carry general liability insurance?* Yes No 28. 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).*Year:Total Revenues ($):Net Income ($):Current Fund Balance ($)* * Fund balance = Total Assets - Total Liabilities29. Within the last five 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 30. 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 SECTION IV.Fiduciary Liability (Available for 100 employees or less):(If “No,” fiduciary will not be offered.)31. Does each pension plan use an outside investment manager?* Yes No 32. 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 32. 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:33. 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:34. 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:35. 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:Virginia Notice: You have an option to purchase a separate Limit of Liability for the extension period, policy common conditions I. If you do not elect this option, the Limit of Liability for the extension period shall be part of and not in addition to the limit specified in the declarations. 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 page 2 of 3information 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: You are agreeing to place coverage in the surplus lines market. Superior coverage may be available in the admitted market and at a lesser cost. Persons insured by surplus lines carriers are not protected under the Florida Insurance Guaranty Act with respect to any right of recovery for the obligation of an insolvent unlicensed insurer. 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 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)Producer Name:* Retail Agency Name:* Title:* Date:* MM slash DD slash YYYY Broker's Signature:*Some states require that we have the name and address of your (insured’s) authorized agent or broker.Name of authorized agent or broker:* Prefix First Last Suffix Address:* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Mail complete application through local agent or broker to: Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code
