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Insurance Types

General Liability

Directors and Officers

Employment Practices

Fiduciary Liability

Workplace Violence

Internet Liability

Directors and Officers Information

If Applicant has current D&O insurance, how many years has it been in force?

List of direct or indirect subsidiaries or other entity Applicant controls

Click the (+) icon to the right to add more Subsidiaries.
Example: ABC Foundation Inc, 100%, 01/01/2020, Non-Profit

Entity Name

Controls %

Date Acquired

For Profit / Non-Profit

Any anti-trust, copyright, or patent litigation in the past 5 years?*

Yes

Any disciplinary action by any regulatory agency or association in the past 5 years?*

Yes

Any action where a license was revoked or suspended in the past 5 years?*

Yes

Any administrative proceeding charging violation of a federal or state law or regulation in the past 5 years?*

Yes

Any other criminal actions in the past 5 years?*

Yes

Does Applicant anticipate being involved with any mergers, acquisitions, or consolidations in the last 24 months or next 12 months?*

Yes

Does Applicant anticipate changes in board of directors or senior management in the last 24 months or next 12 months?*

(other than death or retirement)

Yes

Employment Practices

If Applicant has current EPLI insurance, how many years has it been in force?

Employee counts below should be U.S. based employees/volunteers.

Full Time Employees (Currently)

Full Time Employees (1 Year Ago)

Full Time Employees (2 Years Ago)

Part Time Employees (Currently)

Part Time Employees (1 Year Ago)

Part Time Employees (2 Years Ago)

Temporary Employees (Currently)

Temporary Employees (1 Year Ago)

Temporary Employees (2 Years Ago)

Volunteers (Currently)

Volunteers (1 Year Ago)

Volunteers (2 Years Ago)

Non U.S. employees/volunteers (Currently)

Non U.S. employees/volunteers (1 Year Ago)

Non U.S. employees/volunteers (2 Years Ago)

Does Applicant have an employment handbook?*

Yes

Does Applicant use an employment application for every potential employee?*

Yes

Does Applicant have an "At Will" provision in the employment application or handbook?*

Yes

Has the Applicant implemented an anti-sexual harassment policy?*

Yes

Has the Applicant implemented any anti-discrimination policy?*

Yes

Does the Applicant use outside employment counsel for employment advise?*

Yes

Fiduciary Liability

If Applicant has current Fiduciary Liability insurance, how many years has it been in force?

List plans for Fiduciary coverage

Click the (+) icon to the right to add more Plans.

Plan Name

Established Year

Contributions

Type*

Participants

Administrator**

* Enter the number for the Type of plan

1 - Employee Welfare Benefit Plan (as defined by ERISA)

2 - Defined Contribution Plan (as defined by ERISA)

3 - Defined Benefit Plan (as described by ERISA)

4 - Other

Does any plan(s) employ the investment, trustee, actuarial, legal, administrative, custodial, or benefits consulting services of any outside provider?*

Yes

Has termination been requested or contemplated for any plan?*

Yes

Has any amendment to any plan been made or contemplated within the past 2 years, or is any amendment now contemplated, which has or might result in any reduction of benefits or potential portion of cost?*

Yes

Has any plan been spun-off (sold), transferred, or terminated?*

Yes

Are there or have there been within the last 3 years any known or alleged violations of ERISA or any similar statutory or common law of the U.S.A., Canada, or any other jurisdiction to which a plan is subject?*

Yes

Does the Applicant have any information to suggest or indicate that the plans it sponsors may be under government or regulatory investigation with regard to plan's funding, administration, or investment strategies?*

Yes

Is Form 5500 filed on an annual basis for each plan?*

Yes

Workplace Violence

If Applicant has current Workplace Violence insurance, how many years has it been in force?

Applicant's total number of work locations*

Please enter a number greater than or equal to 0.

Applicant's total number of employees*

Please enter a number greater than or equal to 0.

Does Applicant have an employee assistance program?*

Yes

Does Applicant have a progressive disciplinary policy?*

Yes

Does Applicant have an employee complaint/grievance resolution procedure?*

Yes

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

Yes

Does Applicant train employees to recognize, report, and respond to potentially hostile situations?*

Yes

Does Applicant have a process for performing background checks for all potential employees?*

Yes

In the past 12 months, has Applicant been involved with any layoffs, staff reductions, or facility closings?*

Yes

In the next 12 months, is Applicant contemplating any layoffs, staff reductions, or facility closings?*

Yes

Has Applicant or any other person proposed for coverage herein been subject of, or involved in any incidents of workplace violence in the past 5 years?*

Yes

Internet Liability

If Applicant has current Internet Liability insurance, how many years has it been in force?

Website

Average page views per month

Add Website 2

Add another website

Website 2

Average page views per month

Add Website 3

Add another website

Website 3

Average page views per month

Does the Applicant conduct transactions (e-commerce) on the website?*

Yes

Applicant's projected annual gross revenue from the internet site*

Please briefly describe the type and purpose of the transactions performed on the site*

Current Insurance Coverage

Does Applicant currently have any insurance policies?

(Check all that apply, or choose None)

None

Directors and Officers

EPLI

Fiduciary

Workplace Violence

Internet Liability

General Liability

Professional Liability

D&O Company Name

D&O Limit of Liability

D&O Deductible

D&O Premium

EPLI Company Name

EPLI Limit of Liability

EPLI Deductible

EPLI Premium

Fiduciary Company Name

Fiduciary Limit of Liability

Fiduciary Deductible

Fiduciary Premium

Work Viol. Company Name

Work Viol. Limit of Liability

Work Viol. Deductible

Work Viol. Premium

Int. Liab. Company Name

Int. Liab. Limit of Liability

Int. Liab. Deductible

Int. Liab. Premium

GL. Company Name

GL. Limit of Liability

GL. Deductible

GL. Premium

PL. Company Name

PL. Limit of Liability

PL. Deductible

PL. Premium

With respect to the above coverage, has any Underwriter refused, canceled, or non-renewed coverage?*

Yes

Summary

Has Applicant given written notice under 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 insurance?*

Yes

No person applying for this coverage is aware of any facts or circumstances that may give rise to a claim that would fall within the scope of any proposed coverages for which Applicant has applied*

None

Additional Comments

Additional Files

Drop files here or

Max. file size: 12 MB.

Consent*

The Undersigned states that he/she is an authorized representative of the Applicant and declares to the best of his/her knowledge and belief and after reasonable inquiry, that the statements set forth in the Application (and any attachments submitted with this Application) are true and complete and my be relied upon by Company in quoting and issuing the policy. If any of the information in this Application changes prior to the effective date of the policy, the Applicant will notify the Company of such changes and the Company may modify or withdraw the quote or binder.

The signing of this Application does not bind the Company to offer, or the Applicant to purchase the policy.

I Agree

Signature

Phone

This field is for validation purposes and should be left unchanged.

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