Fill - Free fillable Non Profit Professional Liability Application

OU 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. This is an application for a claims made policy - Please read

your policy carefully. 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)

NPPLA 4/09_2

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Non Profit Professional Liability Application - All States

I. INSTANT QUOTE INFORMATION

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: _________________________________________________________________

Same as mailing address or complete section III.

City:______________________________________________________ State: ______________________ Zip: ________________________

Web Address: _______________________________________ Email Address of primary contact: _____________________________________

Description of Operations:

Total Annual Revenue:______________________________________ (If >$2 million attach the most recent 12-month financial statement)

If less than 3 years in operation, annual revenue: this year : ________________next year:________________3rd 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: ________________________

OMMITTED

AKING

IFFERENCE

II. UNDERWRITING INFORMATION

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

2. Does the organization have tax exempt status by the I.R.S.?

Yes No

3. Does the organization have General Liability Insurance?

Yes No

4. Expiring Information: Carrier ________________________ Limits ______________ Retention ______________ Premium________________

(Attach a statement of details for all “yes” answers to the following questions)

5. Is any entity proposed for Insurance involved in any of the following:

a) Research, development or testing?

Yes No

b) Certification, accreditation or standard-setting?

Yes No

c) Disciplinary actions as a result of peer review activities?

Yes No

d) Administration or sponsorship of any insurance programs?

Yes No

e) Labor/union negotiations or collective bargaining?

Yes No

6. Does the Applicant have any chapters or subsidiaries requiring coverage?

Yes 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?

Yes No

8. a) Within the last 5 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?

Yes No

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?

Yes No

9. Has any Policy for Directors and Officers or Employment Practices Liability ever been cancelled or non-renewed?

Yes No

Submit Application

III. FIDUCIARY (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?

Yes No

2. Does each Plan subject to ERISA comply with all applicable requirements of ERISA and the Internal Revenue

Yes No

Code of 1982, as amended (the “Code”) including: eligibility, participation, vesting, fiduciary responsibility and

funding standards?

3. In the past 2 years has there been or is there now under consideration any material changes to a Plan or

Yes No

termination/consolidation of a Plan?

4. Has there been or is there now pending any claim(s) against any proposed Insured arising out of any Plan?

Yes No

5. Does any proposed Insured have knowledge or information of any act, error or omission which might give rise to a

Yes No

claim under the proposed Fiduciary Liability Coverage?

V. ADDITIONAL APPLICANT INFORMATION

Applicant’s Mailing Address: ________________________________________________________________________________________________

City:______________________________________________________ State: ______________________ Zip: ________________________

irginia Notice: 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.

innesota Notice: 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.

lorida and Illinois Notice: 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

olorado 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.

istrict 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.

lorida 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.

entucky 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.

aine 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.

ew 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.

ew 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.

hio 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.

klahoma 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.

ennsylvania 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.

ennessee 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.

NPPLA 4/09_2- United States Liability Insurance Group

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NPPLA 4/09_2- United States Liability Insurance Group

page 2 of 3

raud 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.

ew York Disclosure Notice: 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 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.

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

Retail Agency Name: ____________________________________ License #: ____________________________________________________________

Main Agency Phone Number: ____________________________________________________________________________________________________

Agency Mailing Address: _________________________________________________________________________________________________________

City: ________________________________________ State: __________________ Zip Code: ___________________________

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.

Applicant’s Signature: ____________________________________________ Title: ________________________ Date: ________________________

President, Chairman, or Executive Director

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