Commercial Nonprofit Insurance Policy Request

List the Agents name you prefer to work with

If unknown, please enter "Lisa"

Nonprofit Business Name *

Tax ID Number *

If available

Website

If available

Your Name*

First NameLast Name

Phone number *

Please enter a valid phone number.

Email*

example@example.com

Desired Policy Start Date*

Date

Please provide names of all board members: *

Please provide a brief description of your operations and mission*

How many years has the nonprofit been in business? *

Business Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Mailing address if different

Any Additional Locations

Annual Gross Revenue*

What are your total fund balances (total assets minus total liabilities)? *

Number of Full Time Employees*

Including owner and all officers

Number of Part Time Employees *

Number of Volunteers *

Does the organization perform any operations located outside the U.S.?*

If yes, where and when established

Does the organization have an anti-harassment and anti-discrimination policy? *

If none, type n/a

Does the organization have tax exempt status by the IRS? *

If none, type n/a

Does the organization carry general liability insurance? If yes, with whom?*

If none, type n/a

Does the organization carry D&O liability insurance currently? If yes, with whom? *

If none, type n/a

Is your organization involved in any of the following? (Attach a statement of details for all “yes” answers to the following):*

Research, development or testingCertification, accreditation or standard-settingDisciplinary actions as a result of peer review activitiesAdministration or sponsorship of any insurance programsLabor/union negotiations or collective bargainingNone of the above

Does your organization have any chapters or subsidiaries requiring coverage? *

If yes, please explain

Has your organization 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? *

If yes, please explain

Have you or any person proposed for coverage (whether or not in the service of you) been the subject of or been involved directly or indirectly in any civil, criminal, regulatory, legislative or administrative proceeding(s)? *

If yes, please provide details

Within the last five 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? *

If yes, please provide details

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? *

If yes, please explain

Has any policy for directors and officers or employment practices liability ever been cancelled or non-renewed? *

If yes, please provide details

What else would you like to share to help us prepare the best policy for you?

If needing Commercial Auto, please include all driver information here including driving license numbers

Do you require Fiduciary Liability Coverage? *

If yes, please complete the questions below

Does each pension plan use an outside investment manager?

Does each plan subject to ERISA comply with all applicable requirements of ERISA and the Internal Revenue Code of 1982, as amended (the “Code”) including: eligibility, participation, vesting, fiduciary responsibility and funding standards?

In the past two years has there been or is there now under consideration any material changes to a plan or termination/consolidation of a plan?

If yes, please explain

Has there been or is there now pending any claim(s) against any proposed insured arising out of any plan?

If yes, please explain

Do you have knowledge or information of any act, error or omission which might give rise to a claim under the proposed fiduciary liability coverage?

If yes, please explain

How did you hear about us? *

Feel free to upload your current policy or declaration pages if available

Thank you for choosing us to assist you with your insurance needs. We are excited to provide you superior service and value.

Dodge Insurance Agency

DodgeAgency@outlook.com

702-827-6007