Fill - Free fillable FLEXI PLUS FIVE APPLICATION AND OFFICERS LIABILITY INSURANCE (Philadelphia Insurance Companies) PDF form

FLEXI PLUS FIVE APPLICATION

NOT-FOR-PROFIT ORGANIZATION DIRECTORS

AND OFFICERS LIABILITY INSURANCE

EMPLOYMENT PRACTICES LIABILITY INSURANCE

FIDUCIARY LIABILITY INSURANCE

WORKPLACE VIOLENCE COVERAGE

INTERNET LIABILITY INSURANCE

THIS I

S AN APPLICATION FOR A CLAIMS MADE POLICY

PLEASE READ YOUR POLICY CAREFULLY

Instructions:

• Whenever used in this Application the term Applicant shall mean the Parent Organization and its wholly-

own

ed/controlled subsidiaries.

• The Applicant is required to complete Sections 1, 2, and 7.

• The Applicant should co

mplete other applicable Section(s) for which

coverage is desired. (See chart

below)

• Please include all requested underwriting information and attachments. Failure to supply may result in

delay.

Chec

k Coverage Desired Section Requested Limit Requested Retention

 General Information

1 N/A N/A

 Directors & Officers

2 $ $

 Employment Practices

3 $ $

 Fiduciary Liability

4 $ $

 Workplace Violence

5 $ $

 Internet Liability

6 $ $

 General Summary

7 N/A N/A

SECTION 1 – GENERAL INFORMATION

(All Applicants must

complete this section)

1. Name of Parent Organization: _________________________________________________________________

2. Address: __________________________________________________________________________________

_________________________________________________________________________________________

Telephone: (_____) _______________________ Internet Address: www._________________________________

3. Standard Industrial Classification (SIC) #: ______________

3a. Federal Employer Identification (FEIN) #:_______________________________________

4. Please describe the nature of the App

licant’s operations:

5. Does the Applicant hav

e a tax-exem

pt status und

er the U.S. Internal Revenue Code?

Yes No If no,

provide an explanation.

___________________________________________________________________________________________

______________________________

_____________________________________________________________

6. The Officer of the Applicant designated to receive any and all notices from the Under

writer or their authorized

representative concerning this insurance is:

_______________________________________________ _____________________ __________________

Name Title E-mail Address

PIIC-NPD-NEW APP NY (05/10) Page 1 of 7

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PIIC-NPD-NEW APP NY (05/10) Page 2 of 7

7. Number of Members: __________________________ Number of Chapters: ________________________

Please attach details for all “YES” ans

wers

to questions 8 – 12.

8. Doe

s the Applicant publ

ish any magaz

ines, periodicals or newsletters?

Yes No

9. Is the App

licant involved in product research, prod

uct development, testing and/or certification?

Yes No

10. Does the Applican

t set standards for the qualificat

ion and performance and/or certify its members?

Yes No

11. Does the Applican

t en

gage in any disciplina

ry actions as a result of peer review activities?

Yes No

12. Does the Applican

t administer or sponsor any in

surance programs for its members?

Yes No

FINANCIAL INFORMATION

CURRENT FISCAL YEAR PREVIOUS

FISCAL YEAR

TOTAL ASSETS: $__________ _______________

$__________________________

NET ASSETS / FUND BALANCE: $_______

__________________ $__________________________

ANNUAL REVENUE: $_________________________ $__________________________

NET REVENUE $__________ _______________

$__________________________

Please attach the most recent annu

al financial audit or 990 form.

SECTION 2 – DIRECTORS AND OFFICERS

(All Applicants must

complete this section)

1. Directors and Officers Liability Insurance has been

continuously in force sin

ce: __________________________

2. Provide a list of all direct and indirect subsidi

aries or

any other entity or organization the Applicant controls:

Percent the Applicant DateCreated/ For Profit /

Name/Type of Business Owns/Controls

Acquired Non-Profit

_____

Example:

ABC Foundation, Inc/ Charitable Children’s Foundation 100% 01/01/2000 Non-Profit

___________________________________________________________________________________________

____

__________________

_____________________________________________________________________

 Additional entities listed by attachment

3. Has the Applicant o

r a

ny person pr

oposed for coverage herein been the subject of, or involved in, any of the

following in the past five (5) years? If y

es, please attach details.

Anti-trust, co

pyright or patent litigation?

Yes No

Any disciplinary action by any regulatory agency or association?

Yes No

Any action where a license was revoked or suspended?

Yes No

Any administrative proceeding charging violation of a federal o

r state law or regul

ation? Yes No

Any other criminal actions?

Yes No

It is agreed that with respect to Question #3, if su

ch circumstances exist, any

claim arising from such

circumstances are excluded from the proposed insurance.

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PIIC-NPD-NEW APP NY (05/10) Page 3 of 7

4. In the past twenty-four (24) months or the next twelve (12) months, has the Applicant been, or anticipate being

involved in an

y of the following?

Mergers, acquisitions or consolidation with another entity? If yes, please attach details.

Yes No

Changes in the board of directors or senior management (other than death or retirement)?

Yes No

If yes, please attach details.

5. Does the Applicant di

rect or request any individual to serve as

director, officer, governor or trustee of any other

entity?

Yes No If yes, please attach details.

SECTION 3 – EMPLOYMENT PRACTICES

(Comple

te this section only

if Employment Practices Liability coverage is desired.)

1. Employment Practices Liability Insurance has been continu

ously in force since

: __________________________

2. Please provide the following employee count information:

U.S. based employees/volunteers: Curre

ntly One Year Ago Two Years Ago

Full Time

employees: ____ ________ ____________ _____________

Part Time employees: ____ ________ ____________ _____________

Temporary employees: ____ ________ ____________ _____________

Volunteers: ____ ________ ____________ _____________

Non U.S. based employees/volunteers: ____________ ____________ _____________

TOTAL SUM OF ABOVE ____________ ____________ _____________

3. How many employees have been terminated or de

moted in the past twelve (12) months?

Voluntary: ____________ Involuntary: ____________ Laid Off: ____________ Demoted: ____________

4. Is any reduction of employees o

r change of statu

s

anticipated in the next year?

Voluntary: ____________ Involuntary: ____________ Layoffs: ____________ Demotions: ___________

5. Does the Ap

plicant

have an employment handbook?

Yes No

6. Does the Applicant use an employmen

t application for every potential employee?

Yes No

7. Does the Applicant have an “At Will” provision in the employment applic

ation or handbook? Yes No

8. Has the Applicant implemented an anti-sexual ha

rassment policy? Yes No

9. Has the Applicant implemented an anti-discrimination policy?

Yes No

10. Does the Applicant use outside emplo

yment counsel for employment advise? Yes No

SECTION 4 – FIDUCIARY LIABILITY

(Complete this section only

if Fiduciary liability coverage is desired.)

1. Fiduciary Liability Insurance has been continuously in force since: ______________________________

2. List all plans for which coverage is requested (use attachment if necessary):

Year Assets/

Plan Name Established Contributions Type* Participants Administrator

Example:

The ABC Children Corp 401K Plan 2000 $1,000,000 2 75 self

a)

b)

c)

d)

* 1=Employee Welfare Benefit Plan (as defined by ERISA), 2

= Defined Contribution Plan (as defined

by

ERISA), 3= Defined Benefit Plan (as defined by ERISA), 4=Other If Type is 3 or 4 a Fiduciary Liability

Supplemental Application must be completed.

Please attach a separate page or use the additional information page provided at the end of the application.

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PIIC-NPD-NEW APP NY (05/10) Page 4 of 7

3. Doe

s any plan(s) employ the investment, trustee, actuarial, legal

, administrative, custodial or benefits consulting

services of any outside provider?

Yes No If yes, please attach details.

4. Has termination been requested or contemplated for any plan?

Yes No

5. Has any amendment to any plan been made or contemplated within the past two (2) years, or is any amendment

now

contemp

lated, which has resulted or might result in any reduction of benefits including, but not limited to, an

increase in participants’ portion of cost?

Yes No If yes, please attach details. If there has been any

amendment(s), please attach copies.

6. Has any plan been sp

un-off (sold), transferred or terminated?

Yes No If yes, please attach details.

7. Are there o

r have there been

within the last three (3) years any known or alleged violations of ERISA or any

similar statutory or common law (including applicable amendments, rules and regulations) of the United States,

Canada or any state or other jurisdiction to which a plan is subject?

Yes No If yes, please attach details.

8. Doe

s the Applicant have any informa

tion to suggest or indicate that any of the plans it sponsors may be under

governmental or regulatory investigation with regard to the applicable plan’s funding, administration or investment

strategies?

Yes No If yes, please attach details.

9. Is Form 55

00 filed on an annual b

asis for each plan? Yes No If yes, provide a copy of the most recent

5500; If no, please attach details.

SECTION 5 – WORKPLACE VIOLENCE

(Complete this section only

if Workplace Violence coverage is desired.)

Please attach a copy of your employee and customer complaint/grievance procedures.

1. Workplace Violence Insurance has been continuously in force since: _________________________________

2. The Appli

cant’s total n

umber of work locations:__________________________________________________

3. The Appli

cant’s total n

umber of employees: _____________________________________________________

4. Does the Applicant:

have an employee assistance program?

Yes No

have a progressive disciplinary policy?

Yes No

have an employee complaint/grievance resolution procedure?

Yes No

have a written policy on workplace violence that is circulated to all employees?

Yes No

train employees to recognize, report, and respon

d to potentially hostile situatio

ns? Yes No

have a process for performing background checks for all potential employees?

Yes No

5. In the past twelve (12) months, has the Applican

t been involved

with any layoffs, staff reductions, or facility

closings?

Yes No If yes, please attach details.

6. In the next twelve (12) months, does the Applicant contempl

ate any layoffs, staff reductions, or facility closings?

Yes No If yes, please attach details.

7. Has the Applicant o

r a

ny person proposed for coverage herein been the subject of, or involved in, any incidents

of workplace violence in the last five years?

Yes No If yes, please attach details.

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PIIC-NPD-NEW APP NY (05/10) Page 5 of 7

SECTION 6 – INTERNET LIABILITY

(Complete this section only

if Internet Liability coverage is desired.)

1. Internet Liability Insurance has been continuo

usly in force sin

ce: _________________________________

2. Please identify the internet site(s) for which coverage is sought, the date each site first went on-line, and

(if known) the average number of page views per month:

Internet site address

Date on-line Average page views per month

____________________________________ ___________ ___________________________

3. Does the Applicant con

duct transa

ctions (e-commerce) on the site or is the site informative only?

 Tra

nsactional / E-commerce (Please complete questions 4, 5 & 6)

 Informational Only (Please go

to question 6)

 Both (Please complete que

stions 4, 5,& 6)

4. The Appli

cant’s pr

ojected annual gross revenues from the internet site: $ __________________________

5. Please describe the type and purpose of the transactions pe

rformed on the site:

___________________________________________________________________________________________

___________

________________________________________________________________________________

6. What percentage of monthly page views on the Applicant’s int

ernet site originates outside the U.S. and

Canada? ___________%

SECTION 7 – GENERAL SUMMARY

(All Applicants must

complete this section.)

1. Has the Applicant give

n written notice un

der the provisions of any prior policies providing similar insurance or

claims, or of specific facts or circumstances which might give rise to a claim being made against any person or

entity applying for this insuranc

e?

Yes No If yes, complete a Claim Supplemental for each incident.

2. No person applying for this coverage is aware of any facts or

circumstance

s which he or she has reason to

suppose might give rise to a future claim that would fall within the scope of any of the proposed coverages for

which the Applicant has applied, except: None

or as noted below:

___________________________________________________________________________________________

___________

________________________________________________________________________________

___________________________________________________________________________________________

3. Current Coverage

COVERAGES

Insurance Company Limit of Liability Deductible Policy Effective Dates Premium

D&O $ $ $

EPLI $ $ $

Fiduciary $ $ $

Workplace

Violence

$ $ $

Internet Liability $ $ $

General Liability $ $ $

Professional

Liability

$ $ $

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PIIC-NPD-NEW APP NY (05/10) Page 6 of 7

4. With respect to the above coverage, has any Underwriter refused, canceled or non-renewed coverage? (Not

Applicable in Missouri)

Yes No If yes, provide details.

___________________________________________________________________________________________

___________

________________________________________________________________________________

Material Change

If there is any material change to the answers of this Applicatio

n’s

que

stion

s prior to the policy inception date, the

Applicant must notify the Underwriter in writing. Any outstanding quotation may be modified or withdrawn.

False Information

WARNING: ANY PERSON WHO KNOWINGLY AND WIT

H INTENT TO DEF

RAUD 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.

NOTICE TO NEW YORK APPLICANTS: A NY PERSON WHO K

NOWINGLY 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 MI SLEADING, INFORMATION CONCERNING ANY FACT MAT ERIAL THERETO,

COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND SHALL ALSO B E SUBJECT TO A

CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE STATED VALUE OF THE CLAIM

FOR EACH SUCH VIOLATION.

Name (Please Print/Type) Title

(MUST BE SIGNED BY THE PRESIDENT

CHAIRMAN OR EXECUTIVE DIRECTOR)

_______________________________________

Signature Date

The above signed warrants that he/she is authorized and has the power to complete and execute this Application,

including the Warranty Statement on behalf of the Applicant and th

eir respective Directors, Officers or other

insured persons.

Produced

By: (Section to be completed by Producer/Broker)

Producer Agency

Producer License Number Agency Taxpayer ID or SS Number

Address (Street, City, State, Zip)

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PIIC-NPD-NEW APP NY (05/10) Page 7 of 7

ADDITIONAL INFORMATION

This page may be used to provide additional information to any question on this

application. Please identify the question number to which you are referring.

__________________________________________ _____________________________________________

Signature Date

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