Fillable Dapp NonProfit Directors Officers NPPLA.indd

Fill Online, Printable, Fillable, Blank Dapp NonProfit Directors Officers NPPLA.indd Form

Use Fill to complete blank online USLI pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Dapp NonProfit Directors Officers NPPLA.indd

On average this form takes 21 minutes to complete

The Dapp NonProfit Directors Officers NPPLA.indd form is 3 pages long and contains:

2 signatures
1 check-box
74 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your USLI forms online.

BROWSE USLI FORMS

Related forms

Fill has a huge library of thousands of forms all set up to be filled in easily and signed.

Fill in your chosen form

Sign the form using our drawing tool

Send to someone else to fill in and sign.

find another form

page 1 of 3

carrier:

NPPLA 5/12 – USLI





YOU CAN OBTAIN A QUOTE BY PROVIDING THE INFORMATION IN THE INSTANT QUOTE SECTION SUBJECT TO THE REMAINDER PROVIDED PRIOR TO BINDING.

All questions must be answered and application must be signed by applicant. 

 Application for Non Profit Directors & Officers Liability Insurance (Coverage Part A) and Employment Practices Liability Insurance (Optional Coverage

Part B) and Fiduciary Liability Insurance (Optional)

Under DO 290 NY, DO 256 NY, DO 281 NY and DO 282 NY, if made part of your policy, the limits of liability available under this

policy may be completely exhausted by the payment of defense costs. Defense costs shall be applied against the retention.



Instant Quote is only available for accounts with no losses in the past 5 years. If there is loss history, please detail the losses below.

Applicant’s name: ________________________________________________________________________________________________

Location address: ____________________________________________________________ q Same as mailing address

City: _________________________________________________ State: ___________________ Zip code: _________________

Website address: _________________________________________

E-mail address of primary contact: ___________________________

Description of operations:

Total annual revenue: $ __________________________________ (If >$2 million attach the most recent 12-month financial statement)

If less than three years in operation, annual revenue: this year : $ ___________ next year: $ ____________third year: $ ______________

Total fund balance (total assets minus total liabilities): $ ___________________________________

Full-time employees: ________________ Part-time: ______________ Temporary/Seasonal: __________ Volunteers: _______________

Does the organization perform any operations located outside the U.S.? _____________ In existence since: ______________________



1. Does the organization have an anti-harassment and anti-discrimination policy? q Yes q No

2. Does the organization have tax exempt status by the I.R.S.? q Yes q No

3 Does the organization have general liability insurance? q Yes q No

4 Expiring D&O information: Carrier: ________________ Limits: $ _________ Retention: $ __________ Premium: $

5 Is any entity proposed for Insurance involved in any of the following. (Attach a statement of details for all “yes” answers to the following

questions):

a) Research, development or testing? q Yes q No

b) Certification, accreditation or standard-setting? q Yes q No

c) Disciplinary actions as a result of peer review activities? q Yes q No

d) Administration or sponsorship of any insurance programs? q Yes q No

e) Labor/union negotiations or collective bargaining? q Yes q No

6. Does the applicant have any chapters or subsidiaries requiring coverage? q Yes q No

7. Has any entity proposed for insurance closed, downsized, laid off, reduced staff, sold, merged with or acquired

any company in the past 12 months or anticipates doing so in the next 12 months? q Yes q No

8. Has the Applicant or any person proposed for coverage (whether or not in the service of Applicant) been the

subject of or been involved directly or indirectly in any civil, criminal, regulatory, legislative or administrative

proceeding(s)? q Yes q No

9. a) Within the last five years, has any inquiry, complaint, notice of hearing, claim or suit been made against any

entity proposed for insurance, or any person proposed for Insurance in the capacity of director, officer, trustee,

employee or volunteer of any entity proposed for insurance? q Yes q No

page 2 of 3

NPPLA 5/12 – USLI

b) Is any person(s) proposed for this Insurance aware of any fact, circumstance or situation which may result in a

claim against any entity proposed for insurance or any of its directors, officers, trustees, employees or volunteers? q Yes q No

10. Has any policy for directors and officers or employment practices liability ever been cancelled or non-renewed? q Yes q No

(AVAILABLE FOR 100 EMPLOYEES OR LESS)

(All questions must be answered in order for fiduciary liability coverage to be bound)

1. Does each pension plan use an outside investment manager? q Yes q No

2. 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? q Yes q No

3. 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? q Yes q No

4. Has there been or is there now pending any claim(s) against any proposed Insured arising out of any plan? q Yes q No

5. 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? q Yes q No



Applicant’s mailing address: ______________________________________________________________________________________

City: _______________________________________________ State: ___________________ Zip: _____________________



 Misrepresentations, omissions, concealment of facts and incorrect statements shall prevent recovery under the policy only if the

misrepresentations, omissions, concealment of facts or incorrect statements are; fraudulent or material either to the acceptance of the risk, or to the hazard

assumed by the insurer or the insurer in good faith would either not have issued the policy, or would not have issued a policy in as large an amount, or would not

have provided coverage with respect to the hazard resulting in the loss, if the true facts had been made known to the insurer as required either by the application

for the policy or otherwise.

 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.

 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.

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.

(Applies only if policy is non-admitted) 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.

 I understand that there is no coverage for punitive damages assessed directly against an insured under Florida

and Illinois law. However, I also understand that punitive damages that are not assessed directly against an insured, also known as “vicariously assessed

punitive damages”, are insurable under Florida and Illinois law. Therefore, if any Policy is issued to the Applicant as a result of this Application and such Policy

provides coverage for punitive damages, I understand and acknowledge that the coverage for Claims brought in the State of Florida and Illinois is limited to

“vicariously assessed punitive damages” and that there is no coverage for directly assessed punitive damages.

Any person who, knowingly and with intent to defraud, presents, causes to be presented or prepares with knowledge or belief that

it will be presented to or by an insurer, purported insurer, broker or any agent thereof, any written statement as part of, or in support of, an application for the

issuance of, or the rating of an insurance policy for personal or commercial insurance, or a claim for payment or other benefit pursuant to an insurance policy

for commercial or personal insurance which such person knows to contain materially false information concerning any fact material thereto; or conceals, for the

purpose of misleading, information concerning any fact material thereto may be guilty of a crime and may be subject to fines and confinement in prison.

 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.

 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. A binder may not be withdrawn but a prospective notice of cancellation

may be sent and coverage denied for fraud or material misrepresentation in obtaining coverage. A policy may not be unilaterally rescinded or voided.

: 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. A binder may not be withdrawn but

a prospective notice of cancellation may be sent and coverage denied for fraud or material misrepresentation in obtaining coverage. A policy may not be

unilaterally rescinded or voided.

Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or

willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

Authorization or agreement to bind the insurance may be withdrawn or modified only 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.

 Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and

civil penalties.

This policy is written on a claims made basis and shall provide no coverage for claims arising out of incidents, occurrences or

alleged Wrongful Acts or Wrongful Employment Acts that took place prior to retroactive date, if any, stated on the declarations. This policy shall cover only

those claims made against an insured while the policy remains in effect for incidents reported during the Policy Period or any subsequent renewal of this

Policy or any extended reporting period and all coverage under the policy ceases upon termination of the policy except for the automatic extended reporting

period coverage unless the insured purchases additional extend reporting period coverage. The policy includes an automatic 60 day extended claims

page 3 of 3

NPPLA 5/12 – USLI

reporting period following the termination of this policy. The Insured may purchase for an additional premium an additional extended reporting period of

12 months, 24 months or 36 months following the termination of this policy. Potential coverage gaps may arise upon the expiration for this extended reporting

period. During the first several years of a claims-made relationship, claims-made rates are comparatively lower than occurrence rates. The insured can expect

substantial annual premium increases independent overall rate increases until the claims-made relationship has matured.

 Notice to North Dakota applicants – Any person who knowingly and with the intent to defraud and 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.

 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.

 By acceptance of this policy, the Insured agrees the statements in the application (new or renewal) submitted to the company

are true and correct. It is understood and agreed that the statements made in the insurance applications are incorporated into, and shall form part of, this policy.

the insured understands and agrees that any material misrepresentation or omission on this application will act to render any contract

of insurance null and without effect or provide the company the right to rescind it.

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.

Notice to Oregon applicants: Any person who, with intent to defraud or knowing that he is facilitation a fraud against an insurer,

submits an application or files a claim containing a false or deceptive statement may be guilty of insurance fraud.

: 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.

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.

I understand that Punitive Damages are not insurable in the state of Utah. There will be no coverage afforded for Punitive Damages for any Claim

brought in the State of Utah. Any coverage for Punitive Damages will only apply if a Claim is filed in a state which allows punitive or exemplary damages to be

insurable. This may apply if a Claim is brought in another state by a subsidiary or additional location(s) of the Named Insured, outside the state of Utah, for which

coverage is sought under the same policy

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.

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 may be subject to fines and confinement in prison.

 This Policy is written on a claims-made basis. Please read the policy carefully to understand your coverage. You have an option to purchase

a separate limit of liability for the extended reporting period. If you do not elect this option, the limit of liability for the extended reporting period shall be part of

the and not in addition to limit specified in the declarations. If you have any questions regarding the cost of an extended reporting period, please contact your

insurance company or your insurance agent. 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.

 Any person who knowingly and with intent to defraud an insurer, submits an Application for insurance or files a claim containing a

false or deceptive statement is guilty of insurance fraud.

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.

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.

 I understand and acknowledge that if a $100,000 or $250,000 Limit of Liability is chosen or if the Insured

Organization has more than 200 employees, that Defense Costs are a part of the Limit of Liability. This means that Defense Costs will reduce my limits of

insurance and may exhaust them completely and should that occur, I shall be liable for any further legal Defense Costs and Damages. Defense Costs are as

defined in Section III. I also understand that the Limit of Liability for the Extended Reporting Period, if applicable, shall be a part of and not in addition to the limit

specified in the Policy Declarations.

If your state requires that we have information regarding your Authorized Retail Agent or Broker, please provide below.

Retail agency name:____________________________________________________ License #: ________________________________________________

Agent’s signature: ______________________________________________________ Main agency phone number: ________________________________

(Required in New Hampshire)

Agency mailing address: __________________________________________________________________________________________________________

City: _______________________________________________________________________ State: __________________ Zip: ______________________

The signer of this application acknowledges and understands that the information provided in this Application is material to the Insurer’s decision to provide the

requested insurance and is relied on by the Insurer in providing such insurance. The signer of this application represents that the information provided in this

Application is true and correct in all matters. The signer of this Application further represents that any changes in matters inquired about in this Application occurring

prior to the effective date of coverage, which render the information provided herein untrue, incorrect or inaccurate in any way will be reported to the Insurer

immediately in writing. The Insurer reserves the right to modify or withdraw any quote or binder issued if such changes are material to the insurability or premium

charged, based on the Insurer’s underwriting guides. The Insurer is hereby authorized, but not required, to make any investigation and inquiry in connection with

the information, statements and disclosures provided in this Application. The decision of the Insurer not to make or to limit any investigation or inquiry shall not be

deemed a waiver of any rights by the Insurer and shall not estop the Insurer from relying on any statement in this Application in the event the Policy is issued. It is

agreed that this Application shall be the basis of the contract should a policy be issued and it will be attached and become a part of the Policy.

 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.

Applicant’s signature:_______________________________________________________________________ Title:____________________________________

President, Chairperson of the Board, Managing Member, or Executive Director

Date:_____________________________________________________

click to sign

signature

click to edit

click to sign

signature

click to edit

Download
Save PDF to desktop

Email
Email completed PDF

Send for Signing
Email for others to sign

Print
Print document

NAME

Dapp NonProfit Directors Officers NPPLA.indd

View Audit Log
Print With Audit Log
Duplicate Document

Fillable Dapp NonProfit Directors Officers NPPLA.indd

Fill Online, Printable, Fillable, Blank Dapp NonProfit Directors Officers NPPLA.indd Form

Related forms

First 20 documents completely FREE!