Exec Pro Nonprofit Solution

Thank you for completing this application. It is being returned to John L Kirby & Associates for immediate processing so we may provide your quote. Your progress will be saved at any point, to complete the application at a later time you must restart from the same computer using the same browser. Your data will be saved for a maximum of 5 days. If you have any questions concerning this questionnaire, please call us for help.

Name of Organization*

Address*

City*

State*

Zip*

Website

Contact*

Email address*

BACKGROUND INFORMATION

Describe the organizations operations:

Annual Salary/wage expense:

Total assets

Provide the financial statements with this Proposal Form if the Organization and its Subsidiaries Total Assets are greater than $5,000,000, Annual Salary/Wages Expense is greater than $500,000, there is claims activity in the last 5 years, or if requested by the underwriter.

Upload here if necessary:

Select File

Does your organization have any subsidiaries?

YesNo

Subsidiary name:

Date of acquisition/creation:

Percent control:

Description of operations:

Operated for:

NonprofitFor-profit

Name of parent organization:

Attach financial statements (if not consolidated) for subsidiary

Select File

COVERAGE IS NOT AUTOMATICALLY PROVIDED FOR ALL SUBSIDIARIES. TERMS AND CONDITIONS OF COVERAGE FOR SUBSIDIARIES ARE DETAILED IN SECTION III. D. OF THE POLICY.

Is the Organization or any of its Subsidiaries involved in or presently considering any merger, consolidation, acquisition, divestment or sale of a portion of its business or has a similar transaction been considered or completed within the last three years? If "Yes" please attach details.

YesNo

If yes please provide details:

Does the Organization or any proposed Insured perform, or are they involved in, any of the following? Check those that apply.

Services involving Children

true

Broadcasting / Publishing

true

Collective Bargaining or Labor Advocacy

true

Lobbying

true

Mental Health / Rehabilitation Counseling

true

Insurance or Investment Advisor

true

Medical Services

true

Foster Care / Adoption

true

Legal or Arbitration Services

true

Research & Development

true

Teacher/ Educator

true

Other Professional Services

true

Financial Counseling

true

Does the Organization take any disciplinary action or recommend disciplinary action as a result of credentials certification, accreditation, licensing, peer review or standard setting activities?

YesNo

Date organized:

Tax status:

taxableTax exempt

501(c)

PRIOR ACTIVITIES / KNOWLEDGE

Have there been during the last five years, or are there now pending, any civil, criminal, administrative or arbitration proceedings (including any proceeding initiated before the Equal Employment Opportunity Commission) brought against the Organization, its Subsidiaries, the Plans of the Organization or its Subsidiaries, or any person proposed for this insurance in their capacity as either Director, Officer, Trustee, employee, volunteer, or staff member of the Organization or its Subsidiaries? If "Yes", for each proceeding please attach details of the complaint, the dollar amount of costs of defense and loss, the date the proceeding was filed, and whether the proceeding is open or closed.

YesNo

Please Explain:

IT IS AGREED THAT ANY CLAIM ARISING FROM ANY PRIOR OR PENDING PROCEEDING IS EXCLUDED UNDER THE PROPOSED COVERAGE.

Is the undersigned or any proposed Insured aware of any fact, circumstance or situation involving the Organization or its Subsidiaries, the Plans of the Organization or its Subsidiaries, or any proposed Insured which he or she has reason to believe might result in a future Claim?

YesNo

Please explain:

IT IS UNDERSTOOD AND AGREED THAT IF KNOWLEDGE OF ANY SUCH FACT, CIRCUMSTANCE OR SITUATION EXISTS, ANY CLAIM SUBSEQUENTLY ARISING THEREFROM SHALL BE EXCLUDED UNDER THE PROPOSED COVERAGE.

SUPPLEMENTAL QUESTIONS (this section must be completed if the Organization and its Subsidiaries Total Assets are greater than $5,000,000, Annual Salary/Wages Expense is greater than $500,000, if there is claims activity in the last 5 years, or if Workplace Violence Coverage is requested.)

Does this apply to your organization?

YesNo

Does the Organization currently have Directors" & Officers" and Employment Practices Liability Insurance?

YesNo

Insurance Carrier

Expiration date

Limit of insurance

Premium

Retention amount

Has any carrier cancelled or non-renewed similar coverage?

YesNo

Provide the number of employees (including officers) at the Organization:

Provide the number of employees and officers whose employment has been involuntarily terminated in the last twelve months and the number of employees and officers whose employment is expected to be involuntarily terminated over the next twelve months through layoffs, facility closings, individual involuntary employee terminations or similar circumstances:

Most recent twelve months:

Number of employees and officers:

Next twelve months:

Number of employees and officers:

Is the turnover rate for the most recent or next twelve months greater than 25%?

YesNo

Please attach additional details including the reason(s) for the involuntary terminations.

In the last twelve months, have there been any changes in the Executive Director or President position for reasons other than death, retirement at the normal retirement age or term limitations?

YesNo

Please provide additional details.

EMPLOYEE BENEFIT PLAN INFORMATION (this section must be completed if a Fiduciary Liability option is requested. Provide Financial Statements for the Plans if Plan assets are greater than $25,000,000.)

Please enter the Total Asset Value for each of the Employee Benefit Plans (referred to as the Plans) sponsored by the Organization or its Subsidiaries for which coverage is desired.

Defined Contribution Plans (including 401(k), 403(b), & 457 Plans)

Total Asset Value

Defined Benefit Plans (including Traditional Pension Plans)

Total Asset Value

Has the Organization or any Subsidiary terminated or contemplated terminating any of the Plans within the past three years or within the next 12 months?

YesNo

Please provide details

Do any of the Plans fail to comply with the "Employee Retirement Income Security Act of 1974" (ERISA) where applicable?

YesNo

Please provide details

Has any Plan had, at any time during the last three years, a funding deficiency?

YesNo

Please provide details

Attention - Applicants in AR, CO. DC, KY, NJ, NM, NY, OH, OK, PA, TN, VA: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 may also be subject to a civil penalty.

In Colorado: 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.

In Florida: Any person who knowing 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.

In New York: 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 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 ($5, 000.00) and the stated value for each such violation.

In Washington, Maine and Louisiana: It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company (including false information in an application for insurance and claim for payment of loss or benefit). Penalties include imprisonment, fines and denial of insurance benefits.

It is agreed the particulars and statements contained in Proposal Forms submitted to the Insurer (and any material submitted therewith) are the representations of the Insured and are to be considered as incorporated in and constituting part of this Policy. It is also agreed this Policy is issued in reliance upon the truth of such representations. However, coverage shall not be excluded as a result of any untrue statement in the Proposal Form, except:

(1) as to any Insured Person making such untrue statement or having knowledge of its falsity; or

(2) as to the Organization and any Subsidiary, if the person(s) who signed the Proposal Form(s) for this coverage or any Insured Person who is or was a past, present or future Chief Financial Officer, President, or Executive Director of the Organization made such untrue statement or had knowledge of its falsity

Signature of executive Director*

Dated*

Date