Fillable NonProfit Directors And Officers Liability Application 310002-P (4/97) page 1 of 11

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NonProfit Directors And Officers Liability Application 310002-P (4/97) page 1 of 11

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Page 1 of 11
NON-PROFIT ORGANIZATION DIRECTORS AND OFFICERS LIABILITY APPLICATION
1. Legal name of the business which is the primary applicant and will be the first named insured listed on the policy:
2. Please list all other business/dba names, including subsidiaries for which you are seeking coverage under this policy:
3. Are all applicant entities and all requested business/dba names and subsidiaries organized as Yes No
non-profit entities. Please explain any “no” response.
4. Please list any names of other entities that you own or manage or that you do business under (such entities are not
requesting coverage under this policy):
5. Primary location address:
6. County of primary location: Date business originally established:
7. Total number of branches: List all addresses for additional branches:
8. What is your web-site address? www.
9. What is your phone number?
10. Has the name or ownership of the entity changed or has any other business been purchased, Yes No
merged or consolidated with the entity within the last 5 years?
11. Does any entity own or control your business or does your business own or control any entity? Yes No
12. During the past five years, has your name been changed or has any other business purchased, Yes No
merged or consolidated with you?
For questions 9-11, please fully explain any “yes” response, including the names, dates, and revenue impact involved:
13. Please list any associations of which you are a member:
14. Does the Applicant now have tax exempt status under the United States Internal Revenue Service? Yes No
15. Is there now, or has there been, any dispute as to the Applicant’s tax exempt status? Yes No
If Yes, please attach an explanation.
16. Please describe the nature of the Applicant’s business (type of product or services provided).
1. Does the Applicant have any subsidiaries or control any other entity or organization for Yes No
which coverage is requested?
If Yes, please attach a description of operations, ownership, and tax status for each such entity.
2. In the next 12 months (or during the past 24 months) is the Applicant contemplating (or has
the Applicant completed or been in the process of completing) the following:
a. Any actual or proposed merger, acquisition, or divestiture? Yes No
b. Any creation of a new organization, subsidiary, or division? Yes No
c. Any reorganization or arrangement with creditors under federal or state law? Yes No
GENERAL INFORMATION
ORGANIZATION INFORMATION
Kinsale Insurance Company
P. O. Box 17008
Richmond, VA 23226
(804) 289-1300
www.kinsaleins.com
Page 2 of 11
d. Any branch, location, facility, office, or subsidiary closings, consolidations, or layoffs? Yes No
If any of the questions above were answered Yes, please attach an explanation, including the timing, the essential terms
of the event, arrangement, impact on employee base and the surrounding circumstances.
3. Does the Applicant perform any of the following services:
If Yes, please attach an explanation.
a. Professional ethics, peer review, or accreditation activities, directly or through Yes No
third parties?
b. Organize or sponsor any type of contest, lottery, tournament, prize, give-away, Yes No
raffle or other game of chance?
c. Publishing, including a newsletter? Yes No
d. Operate or sponsor a political action committee? Yes No
e. Provide, sponsor or promote any form of insurance or investments to members Yes No
or non-members?
f. Operate or sponsor a referral service, legal aid service, or computer service to its members Yes No
or non-members?
g. Performing or sponsoring product or service research, experimentation, standards Yes No
development, performance or testing?
h. Provide arbitration services or negotiate labor contracts? Yes No
i. Provide administrative or management services for any other entity(ies)? Yes No
j. Certification, endorsement, or licensing of members or members’ products/ Yes No
services?
k. Organize, promote or sponsor any type of group travel, convention, parade, or similar Yes No
event, or assume liability in connection therewith?
4. Is the Applicant managed or administered by any third party under contract or agreement? Yes No
5. Does the Applicant manage or administer any entity (other than the Applicant Entity) under Yes No
contract or agreement? If Yes, please attach an explanation.
6. Does the Applicant currently carry General Liability Insurance? Yes No
7. If applicable, indicate the following: Number of Members ________ Numbers of Chapters __________ N/A _______
1. Complete the following chart providing the requested financial information:
Indicate the following as it relates to
the Applicant’s fiscal year end (FYE):
(Please indicate negative figures with “( )” or “-“ as appropriate)
Most Recent FYE
(Month/Year)
(_____/_____)
Prior FYE
(Month/Year)
(_____/_____)
Total Assets $ $
Long Term Debt $ $
Net Equity/Net Assets (Deficit Equity)
$
$
Revenues $ $
Net Income (Net Loss)
$
$
2. Is the Applicant currently (or has it been in the past 24 months) in violation of, or has Yes No
it received an amendment to any debt covenant?
If Yes, please attach an explanation.
FINANCIAL INFORMATION
Page 3 of 11
1. Number of Employees: Full Time: Part Time:
2. Number of Volunteers: How many hours per week do volunteers work on average?
3. Please describe the services performed by Volunteers for or on behalf of your Organization.
4. Salary Ranges Number of full Number of part
(including bonuses, dividends and commissions) time employees time employees
$50,000 or less:
$50,001 to $100,000:
$100,001 and over:
TOTAL:
If you have multiple locations, please list employees by state:
State:
State:
State:
State:
State:
Full-Time
Part-Time
Volunteers
5. Does the Applicant use seasonal or temporary employees? Yes No
If so, when and how many?
Are these employees included in #4 above? Yes No
6. Does the Applicant use leased workers? Yes No
If Yes, how many have been retained by the Applicant in the past 12 months?
Are these employees included in #4 above? Yes No
7. Does the Applicant use independent contractors? Yes No
If Yes, how many work solely for the Applicant?
8. How many employees are covered by collective bargaining or other union agreements?
9. In the past 12 months, how many
officers
Of the above, how many were terminated?
have left your employ?
10. In the past 12 months, how many
other employees
Of the above, how many were terminated?
have left your employ?
1. In the past twelve (12) months, has your total number of employees decreased by more Yes No
than ten percent (10) or five (5) employees, whichever is greater, through any reduction
in force, systematic lay-off, closure of any division, office or facility that you own or operate
or for any other reason? (If Yes, please complete the Reduction In Force supplement.)
EMPLOYEES
(including Subsidiary employee information on a separate sheet)
EMPLOYMENT PRACTICES
Page 4 of 11
2. In the next twelve (12) months, do you anticipate the total number of your employees Yes No
to decrease by more than ten percent (10%) or five (5) employees, whichever is greater,
through any reduction in force, systematic lay-off, closure of any division, office or facility
that you own or operate or for any other reason? (If Yes, please complete the Reduction
In Force supplement.)
3. If during the next 12 months, circumstances of which are you currently unaware make it Yes No
necessary for you to decrease the number of your employees by ten percent (10%) or five (5)
employees, whichever is great, through the implementation of any reduction in force,
systematic layoff, closure of any division, office or facility that you own or operate or for any
other reason (with any such reduction, lay-off or closure not known, anticipated or planned by
you as of the date of this Application), do you agree that you will consult with, and adopt the
advice of, a lawyer who specializes in labor and employment law (may include in-house
counsel, but only if that counsel if qualified and experienced in the practice of labor and
employment law) as respects the implementation of such reduction, lay-off or closure?
(If No, please explain on a separate sheet.)
4. Does the Applicant anticipate any merger, acquisition, or addition of any operations that Yes No
would comprise a twenty-five percent (25%) or ten (10) employees, whichever is greater,
increase over the current number of employees? (If Yes, please provide full details on a
separate sheet.)
5. Has any insurer ever cancelled or non-renewed the Applicant or its predecessor for this Yes No
type of coverage? (If Yes, please provide details on a separate sheet.)
1. Does the Applicant have written employment agreements with all officers? Yes No
2. Have the Applicant’s managers and/or supervisors attended training and education programs/ Yes No
seminars on sexual harassment and other types of discrimination within the last 12 months?
If Yes, who has attended?
If Yes, who conducts the sessions?
3. Does the Applicant have its employment policies/procedures reviewed by labor or employment Yes No
counsel?
If Yes, identify the firm and date of last review:
4. Does the Applicant have a Human Resources or Personnel Department? Yes No
If No, who handles this function?
5. Does the Applicant have an employee handbook? Yes No
If Yes, does the Applicant distribute it to all employees? Yes No
If Yes, do all employees sign up for its receipt? Yes No
If Yes, does it expressly state that it is not a contract and that employment is “at will”? Yes No
6. Does the Applicant have written procedures for handling employee complaints of discrimination Yes No
and/or sexual harassment?
7. Does the Applicant require all terminations to be reviewed by:
The person in charge of human resources? Yes No
Outside counsel? Yes No
8. Does the Applicant maintain a personnel file for each employee? Yes No
HUMAN RESOURCES
Page 5 of 11
1. Estimated number of employees with customer/client contact:
2. Please describe the frequency and nature of customer/client interactions.
3. Has the Applicant or its predecessors ever received a complaint, formal or informal, from a Yes No
non-employee, such as a customer, client, or prospective customer or client complaining about
discrimination or harassment by the Applicant or any employee of the Applicant?
(If Yes, please provide details on a separate sheet.)
4. Does the Applicant conduct staff training on client and customer relations issues such as Yes No
avoiding discriminatory behavior?
5. Are there procedures for reporting and dealing with complaints by customers/clients? Yes No
6. Is the Applicant in compliance with Title III of the Americans with Disabilities Act Yes No
(building and premises requirements)?
1. After inquiry with each person as appropriate does anyone have any other Material Facts to Yes No
disclose? (If Yes, please provide such Material Facts on a separate sheet.)
A Material Fact is one likely to influence assessment of this risk, the premium charged or the terms and conditions
imposed by Underwriters. If you are in any doubt as to whether a fact would be considered material, you should
disclose it. All of the information requested in this proposal is material.
1. Provide your firm’s recent Non-Profit D&O insurance history below:
Insurance
Limits Per Claim/
Deductible
Policy Period
(Month/Day/Year)
Retro
Date
Annual
Premium
Current Year
Previous Year 1
Previous Year 2
Previous Year 3
Previous Year 4
2. Does your expiring D&O policy also include Employment Practices Liability (EPL) insurance? Yes No
If “No”, do you have a separate Employment Practices Liability (EPL) policy in place? Yes No
If “Yes”, please proceed to question #3. If “No”, please proceed to question #4.
THIRD PARTY INFORMATION
OTHER MATERIAL INFORMATION
INSURANCE AND LOSS HISTORY
Page 6 of 11
3. Provide your firm’s recent Employment Practices Liability insurance history below:
Insurance
Limits Per Claim/
Deductible
Policy Period
(Month/Day/Year)
Retro
Date
Annual
Premium
Current Year
Previous Year 1
Previous Year 2
Previous Year 3
Previous Year 4
If requesting prior acts coverage you will be asked upon binding coverage to provide a copy of your current insurance
declaration page documenting the expiring retroactive date and limits. Prior acts coverage may not be available if the
date of your current retroactive coverage is different from what we have quoted or if there is any gap between
effective dates.
4. Are you being canceled or non-renewed by your current non-profit D&O or employment practices Yes No
liability carrier?
If Yes, please explain why:
5. Requested Limits: $100,000/$300,000 $250,000/$250,000 $500,000/$500,000 $1,000,000/$1,000,000
Other $ /$
Requested Deductible (Per Claim): $5,000 $10,000 $25,000 Other
6. After inquiry with each person as appropriate, in the last five (5) years, have any Directors and Yes No
Officers claims, or any wrongful termination discrimination, sexual harassment claims or any other
wrongful employment practices liability claim or suit, including third party claims, ever been made
against the Firm or any predecessor firm or any current or former member of the Firm or predecessor firm?
If “Yes,” how many? Please complete a separate Supplemental Claim Form
for each claim or suit and include a currently valued loss run for each claim.
7. After inquiry with each person as appropriate, do you, or any of your partners, officers, Yes No
directors, or employees know of any circumstances, acts, errors, omissions, or any allegations
or contentions of any incident that could result in a Directors or Officers claim, or any employment
related claim, including third party claims?
If “Yes,” how many? If “Yes,” please complete a separate Supplemental
Claim Form for each potential claim and provide as much details as possible.
8. Of the total number of EEOC/state agency charges filed against any Applicant over the last five years, indicate the
number of primary allegations as follows:
Page 7 of 11
1) Location No. 2) Racial
Discrimination
3) Age
Discrimination
4) Religious
Discrimination
5) Other Ethic
Discrimination
6) Equal Pay
Act Violation
7) Other
Gender
Discrimination
8) Violation of
Am. With
Disabl. Act
9. With respect to litigated cases (including wrongful termination suits under state law other than antidiscrimination law)
and EEOC/state agency charges over the last five years for which any settlement was or may be paid, please provide the
following information, which must be currently valued:
Date
Occurrence
Claimant Allegation Damages Paid Damages Reserved Legal Expenses
Paid
Legal Expenses
Reserved
As part of this Application, please submit the following documents (these documents, and the representations and facts
they contain, are made a part of this Application, whether such documents are physically delivered to the Company by the
Applicant or are obtained by the Company from any public source, including the Internet):
• Most recent annual audited financial statement.
• IRS Form 990.
• Copy of Applicant mission statement.
• If Applicant is a start-up, a copy of the organization plan and list of outside affiliations of Directors and Officers.
• If Applicant is a country club, a copy of club rules, constitution and by-laws.
• If Applicant is a school, complete the School Supplemental Application.
• If impact of Applicant layoffs is either 10% of the workforce or more than 100 employees, complete the Downsizing
Supplemental Application.
FRAUD WARNING
NOTICE TO ALABAMA, ALASKA, ARIZONA, ARKANSAS, CALIFORNIA, CONNECTICUT, DELAWARE, GEORGIA, IDAHO, ILLINOIS, INDIANA, IOWA, KANSAS,
MARYLAND, MASSACHUSETTS, MICHIGAN, MINNESOTA, MISSISSIPPI, MISSOURI, MONTANA, NEBRASKA, NEVADA, NEW HAMPSHIRE, NORTH
CAROLINA, NORTH DAKOTA, OREGON, RHODE ISLAND, SOUTH CAROLINA, SOUTH DAKOTA, TEXAS, UTAH, VERMONT, WASHINGTON, WEST VIRGINIA,
WISCONSIN, AND WYOMING APPLICANTS: In some states, 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, for the purpose of misleading, conceals
information concerning any fact material thereto, may commit a fraudulent insurance act which is a crime in many states.
NOTICE TO COLORADO APPLICANTS: 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 policy holder or
claimant for the purpose of defrauding or attempting to defraud the policyholder or claiming with regard to a settlement or award payable for insurance
proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.
NOTICE TO DISTRICT OF COLUMBIA APPLICANTS: 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.
NOTICE TO FLORIDA APPLICANTS: Any person who knowingly and with intent to injure, defraud or deceive any insurance company files a statement of
claim containing any false, incomplete or misleading information is guilty of a felony of the third degree.
NOTICE TO HAWAII APPLICANTS: For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or
benefit is a crime punishable by fines or imprisonment, or both.
REQUIRED ATTACHMENTS
Page 8 of 11
NOTICE TO KENTUCKY APPLICANTS: 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.
NOTICE TO LOUISIANA APPLICANTS: 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.
NOTICE TO MAINE APPLICANTS: 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 denial of insurance benefits.
NOTICE TO NEW JERSEY APPLICANTS: Any person who includes any false or misleading information on an application for an insurance policy is subject to
criminal and civil penalties.
NOTICE TO NEW MEXICO APPLICANTS: 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 civil fines and criminal penalties.
NOTICE TO NEW YORK APPLICANTS: Any person who knowingly and with intent to defraud an 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 $5,000 and the stated value
of the claim for each such violation.
NOTICE TO OHIO APPLICANTS: Any person who, with intent to defraud or knowing that he/she 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.
NOTICE TO OKLAHOMA APPLICANTS: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes a any claim
for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.
NOTICE TO PENNSYLVANIA APPLICANTS: Any person who knowingly and with intent to defraud any insurance company, or other person, files an
application for insurance or statement of a 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 the person to criminal and civil penalties.
NOTICE TO TENNESSEE APPLICANTS: 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.
NOTICE TO VIRGINIA APPLICANTS: 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.
The Applicant acknowledges that the answers provided herein are based on a reasonable inquiry and/or investigation. The Applicant warrants that the
above statements and particulars together with any attached or appended documents are true and complete and do not misrepresent, misstate or
omit any material facts.
The Applicant agrees to notify us of any material changes in the answers to the questions on this questionnaire which may arise prior to the effective
date of any policy issued pursuant to this questionnaire and the Applicant understands that any outstanding quotations may be modified or withdrawn
based upon such changes at our sole discretion.
Completion of this form does not bind coverage. Applicant’s acceptance of the company’s quotation is required prior to binding coverage and policy
issuance.
All written statements and materials furnished to the company in conjunction with this application are hereby incorporated by reference into this
application and made a part of this application.
Applicant: Title:
(Must be signed by a Director of Human Resources or other
Principal, Partner, or Officer of the Firm)
Applicant’s Signature: Date:
Agent/Broker Name:
click to sign
signature
click to edit
Page 9 of 11
NONPROFIT
DIRECTORS AND OFFICERS LIABILITY SUPPLEMENTAL CLAIM APPLICATION
This form is to be completed when the Applicant has been involved in any claim or is aware of an incident which
may give rise to a claim. COMPLETE ONE FORM FOR EACH CLAIM OR INCIDENT.
If space is insufficient to answer any questions fully, attach a separate sheet.
In lieu of attaching suit papers, please provide a complete narrative description of the allegations involved
1. Full Name of Applicant:
2. Full Name of Individual(s) or entity involved in the claim:
3. Additional defendants
4. Full Name of Claimant:
5. Is the Claimant still your client after bringing the claim? Yes No
Before or after this claim, did you perform other professional services for this Claimant unrelated Yes No
to this claim?
If Yes to either question, please explain.
6. Before this claim, had you sued or otherwise pursued collection efforts against the Claimant for Yes No
unpaid fees for your professional services?
7. Indicate whether: CLAIM SUIT Incident/Circumstance Only (no claim or suit)
8. Date and location of alleged act, error or omission:
9. Date of claim: Date reported to Insurance Company:
10. What is the status of the claim? Closed/Settled Open/Pending Incident/Circumstance
11. IF CLOSED:
Total paid including deductible(s)? Responses such as “unknown” or “unavailable” are insufficient.
Defense costs
Loss/compensatory damages
Paid by you-out of pocket $ $
Insurance Company $ $
Date Resolved: _____/_____/_____ Trial Out of Court
12. IF PENDING:
(a) Claimant’s settlement demand? $ _____ Defendant’s settlement offer (if any): $
APPLICANT’S INFORMATION
Kinsale Insurance Company
P. O. Box 17008
Richmond, VA 23226
(804) 289-1300
www.kinsaleins.com
Page 10 of 11
(b) Insurer’s reserve amounts? Loss $ Defense $
(c) Amounts already spent defending the claim? By you? $ By the insurer? $
(d) What is your best estimate of the likely settlement amount for this matter? $
(e) What is your best estimate of the date when you expect this claim to be resolved?
Note: Answering “unknown” or “unavailable” to the above questions is an insufficient response.
13. Name(s) of Insurer(s) responding to this claim or incident
Policy Number:
Limits of Liability: Deductible:
14. Provide narrative description of suit, claim or incident, including the allegations involved, the potential size of injury
and your response:
15. Explain what action(s) have been taken to prevent reoccurrence of a similar claim:
______
_____
I declare that the information submitted herein is true to the best of my knowledge and becomes a part of my
Professional Liability Application. I understand that an incorrect or incomplete statement could void my
protection.
Signature of Applicant/Title/Date (Must be signed by a Principal, Partner or Officer of the Firm)
FRAUD WARNING
NOTICE TO ALABAMA, ALASKA, ARIZONA, ARKANSAS, CALIFORNIA, CONNECTICUT, DELAWARE, GEORGIA, IDAHO, ILLINOIS, INDIANA, IOWA, KANSAS,
MARYLAND, MASSACHUSETTS, MICHIGAN, MINNESOTA, MISSISSIPPI, MISSOURI, MONTANA, NEBRASKA, NEVADA, NEW HAMPSHIRE, NORTH
CAROLINA, NORTH DAKOTA, OREGON, RHODE ISLAND, SOUTH CAROLINA, SOUTH DAKOTA, TEXAS, UTAH, VERMONT, WASHINGTON, WEST VIRGINIA,
WISCONSIN, AND WYOMING APPLICANTS: In some states, 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, for the purpose of misleading, conceals
information concerning any fact material thereto, may commit a fraudulent insurance act which is a crime in many states.
NOTICE TO COLORADO APPLICANTS: 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 policy holder or
claimant for the purpose of defrauding or attempting to defraud the policyholder or claiming with regard to a settlement or award payable for insurance
proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.
NOTICE TO DISTRICT OF COLUMBIA APPLICANTS: 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.
NOTICE TO FLORIDA APPLICANTS: Any person who knowingly and with intent to injure, defraud or deceive any insurance company files a statement of
claim containing any false, incomplete or misleading information is guilty of a felony of the third degree.
NOTICE TO HAWAII APPLICANTS: For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or
benefit is a crime punishable by fines or imprisonment, or both.
NOTICE TO KENTUCKY APPLICANTS: 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.
NOTICE TO LOUISIANA APPLICANTS: 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.
NOTICE TO MAINE APPLICANTS: 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 denial of insurance benefits.
Page 11 of 11
NOTICE TO NEW JERSEY APPLICANTS: Any person who includes any false or misleading information on an application for an insurance policy is subject to
criminal and civil penalties.
NOTICE TO NEW MEXICO APPLICANTS: 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 civil fines and criminal penalties.
NOTICE TO NEW YORK APPLICANTS: Any person who knowingly and with intent to defraud an 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 $5,000 and the stated value
of the claim for each such violation.
NOTICE TO OHIO APPLICANTS: Any person who, with intent to defraud or knowing that he/she 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.
NOTICE TO OKLAHOMA APPLICANTS: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes a any claim
for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.
NOTICE TO PENNSYLVANIA APPLICANTS: Any person who knowingly and with intent to defraud any insurance company, or other person, files an
application for insurance or statement of a 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 the person to criminal and civil penalties.
NOTICE TO TENNESSEE APPLICANTS: 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.
NOTICE TO VIRGINIA APPLICANTS: 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.
The Applicant acknowledges that the answers provided herein are based on a reasonable inquiry and/or investigation. The Applicant warrants that the
above statements and particulars together with any attached or appended documents are true and complete and do not misrepresent, misstate or
omit any material facts.
The Applicant agrees to notify us of any material changes in the answers to the questions on this questionnaire which may arise prior to the effective
date of any policy issued pursuant to this questionnaire and the Applicant understands that any outstanding quotations may be modified or withdrawn
based upon such changes at our sole discretion.
Completion of this form does not bind coverage. Applicant’s acceptance of the company’s quotation is required prior to binding coverage and policy
issuance.
All written statements and materials furnished to the company in conjunction with this application are hereby incorporated by reference into this
application and made a part of this application.
Applicant: ______________________________________ Title:
(Must be signed by a Principal, Partner, or Officer of the Firm)
Applicant’s Signature: _____________________________ Date:
Agent/Broker Name:
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NonProfit Directors And Officers Liability Application 310002-P (497) page 1 of 11

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Completed 2 July 2020

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