Directors & Officers Liability Application

Directors & Officers liability provides protection for claims arising out of allegations of errors, omissions or wrongful acts committed by its directors, officers, employees or volunteers. Coverage will respond to allegations of discrimination against a third party, acts beyond granted authority, failure to deliver services, wrongful dismissal, and wrongful employment practices. Coverage is provided on a Claims-made basis, applying only to claims first made during the coverage period.

Coverage also includes EPLI (Employment Practices Liability): Employment Practices Liability Insurance (EPLI) includes coverage for defense costs and damages related to various employment-related (including volunteers of non-profits); claims including allegations of Wrongful Termination, Discrimination, Harassment and Retaliation.

ELIGIBILITY

Non profit organizations that meet all the following criteria:

Organization has tax exempt status as a not-for-profit organization
Annual revenue of the organizations from all sources is $5,000,000 or less
The Organization must not be a government entity or organization

PLEASE SELECT ONE*

Applying for New PolicyRenewing Coverage

Date Coverage is due to renew*

Organization Name*

Date Organization Incorporated*

Date

Contact Person (to whom all policies and billing statements will go)*

First NameLast Name

Phone Number*

Please enter a valid phone number.

Email*

example@example.com

Mailing Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Website (if any)

Provide a detailed description of your operations and events*

Organization Tax ID #*

Date Organization Incorporated*

Organization Financial Information from prior year financial statements. This must be completed as accurately as possible. If a new organization please provide estimate*

	2023
TOTAL GROSS RECEIPTS FROM FINANCIAL STATEMENT
TOTAL ASSETS FROM FINANCIAL STATEMENT
TOTAL LIABILITIES FROM FINANCIAL STATEMENT

Employees/Volunteers*

	#
# FULL TIME EMPLOYEES
# PART TIME EMPLOYEES
# VOLUNTEERS (board members, officers, coaches, steerers etc)

Does organization currently have D&O coverage in force?*

YESNOHad coverage within past year but cancelled

Enter details of current or prior coverage*


CURRENT CARRIER NAME
EXPIRATION / CANCELLATION DATE
PREMIUM
LIABILTIY LIMIT
HAS YOUR ORGANIZATION HAD A CLIAM IN PAST 5 YEARS

Do any Directors or Officers of the Organization currently serve on any other non-profit boards.*

NOYES

Select the Liability Limits Required. Limits are per policy term. Defense costs are outside the limits. The indicated premium is based on Organizations Annual Gross Revenue of up to $1,000,000. The premium indicated is annual and includes a $20 Risk Purchasing Group Fee. If your gross revenue is over $1,000,000 a quote will be provided.*

$1,000,000/$1000 retention (deductible). $816.00$2,000,000/$1,000 retention. $1,175.00

What date do you want coverage to begin?. Coverage cannot be back-dated. *

Date

I confirm that the informatio provided is true and correct to the best of my knowledge. MUST BE SIGNED BY AN OFFICER/DIRECTOR OF THE ORGANIZATION.

Signature of Authorized Officer, Director, or Treasurer *

Name of Person Completing Application*

First NameLast Name

Designation*

Date*

Date

REMINDER:

Premium is 100% fully earned at inception and non refundable.
The Risk Retention Group Administration fee included in the premium is assessed by the wholesale producer not Paddlesport Risk Management.
Coverage can only be obtained by remitting a signed and completed application along with payment in full
Incomplete applications will be declined and returned.
Coverage will not be made effective prior to the date that the completed application and payment have been received. Submission of this application does not bind coverage. Once your application is approved you will be sent an email with premium payment instructions.
If submitting your application after business hours or after 1pm on a Friday coverage may not start until the next business day.

ONCE COVERAGE IS BOUND YOU WILL BE SENT A FORMAL PRE-FILLED APPLICATION TO SIGN.

PLEASE CALL OR EMAIL WITH ANY QUESTIONS.

Phone: (631) 321-6859

Email: Paddlesports@jacka-liquori.com

NON-PROFIT SPORTS DIRECTORS AND OFFICERS including EPLI APPLICATION