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Request a Quote

Associations and Not For Profit Company Insurance Questionnaire

General Application Information

(Required *)

Complete Business Name: *
Mailing Address/Street:
City/State/Zip:
Location Address/Street (if different from mailing):
City/State/Zip:
Primary Contact Name: *
Contact Title:
Phone Number: *
Fax Number:
Email Address: *
Web Site Address:
Type of Entity
(Sole Proprietor, Corporation, Partnership, LLC, etc)
:
Federal ID Number:
Type of Business:
(Describe typical services performed, customers served, products provided, etc.) :
Do you set standards or provide any certifications? No Yes
Do you utilize volunteers? In what function, how many and how often?
Do you have any foundations or for-profit ventures? Are these operating under another separate entity name?
Please describe operations and relationship to the main organization:
Years In Business:
If New Venture, prior experience:
Do you work or sell product overseas? Yes       No
Do you have a board of directors? Yes       No
Describe special events you hold:
(annual conference, fundrasing activities, etc.)
Do any of these events generate a large amount of income for your organization that, if cancelled, would cause a significant loss of money in unreimbursable expenses?
If this applies to you, please describe:
   
Current Insurance Information
Current Insurance Carrier (Name of Insurance Company):
How Long Insured:
Date(s) Policy(s) Expire:
Reason for Seeking New Carrier:
   
Location / Building Information
  LOCATION 1 LOCATION 2 LOCATION 3
Construction:
# of Stories:
Year Built (approx.):
If over 30 years old, years of updating for
Wiring
Heating
Plumbing
Roof
Wiring
Heating
Plumbing
Roof
Wiring
Heating
Plumbing
Roof
Square Footage:
Owner? No Yes No Yes No Yes
Tenant? No Yes No Yes No Yes
Alarms? Burglar
Fire
Local
Central Station
Burglar
Fire
Local
Central Station
Burglar
Fire
Local
Central Station
Sprinklers? No Yes No Yes No Yes
   
   

Coverage/Rating Basis Information

Property
Replacement Value of Contents:
Should include Leasehold Improvements(may also be included in building so obtain a breakdown), Leased Property, Inventory, Furniture/Fixtures, Equipment, Printed Materials, Consumables, Property of Others
$
Replacement Value of Building, if applicable: $
Replacement Value of Computer Hardware: $
Valuable Papers: $
Accounts Receivable: $
Other property or equipment (specify what): $
Business Property Used/Transported/Stored Off-Premises: $
Exterior Sign? No Yes
Exterior Glass? No Yes
Business Income: $
 
General Liability
Each Occurrence Limit Desired: $
Estimated Annual Gross Receipts: $
Estimated Annual Total Payroll $
Number of Full Time Employees:
Number of Part Time Employees:
Do you use sub-contractors?: No Yes

If yes, for what purposes?:

Do you require sub-contractors to carry insurance and do you obtain certificates of insurance?:

No Yes
 
Worker's Compensation by State
State Classification/Duties:   Est. Annual Payroll:  Number of Employees:
$
  Classification/Duties   Est. Annual Payroll:  Number of Employees:
$
  Classification/Duties   Est. Annual Payroll:  Number of Employees:
$
  Classification/Duties   Est. Annual Payroll:  Number of Employees:
$
 
Owner/Officer Information
Name   Title  Duties  Incl/Excl
Name   Title  Duties  Incl/Excl
Name   Title  Duties:  Incl/Excl
Name   Title  Duties  Incl/Excl
 
Automobile
Comprehensive Deductible: $
Collision Deductible: $
Rented Vehicles used or Employee Vehicles Used in Business? No Yes

If yes, number of rental car days/year:

If non-owned, how many employees drive their cars frequently for company business:

If any key employees have company vehicles and do not buy a personal auto policy for their protection while driving for personal use (Drive Other Car Coverage ), list their names:
   
Owned Vehicle Schedule
NOTE: You may complete with Vehicles and Drivers below, or fax us your list at 301-417-0040

YEAR

MAKE / MODEL

COST NEW

GARAGING CITY/STATE

RADIUS

USE in YEARS

Drivers Schedule (if you own vehicles)
(List all employees who drive any vehicle on company business).

NAME

DATE OF BIRTH

DRIVERS LIC #

STATE

ACCIDENTS/VIOLATIONS WITHIN LAST 3 YEARS

 
Prior Claim/Loss Information

Have you had any prior claims or losses? No Yes

IMPORTANT: IF YOU ANSWERED YES ABOVE, PLEASE CALL YOUR CURRENT AGENT AND REQUEST A COPY OF YOUR CLAIMS HISTORY (OR “LOSS RUNS”) FOR THE LAST THREE YEARS FOR ALL OF YOUR POLICIES.

 
Other Optional Coverage to Consider
Do you need coverage for trips or work outside the United States? No Yes
Would you like an optional Umbrella Quote? No Yes
Would you like an Employee Benefits Quote (health, life, disability, long-term care)? No Yes
Would you like a Directors and Officers Liability Quote? No Yes
Interested in Any Other Coverage Not Shown Above?
 
        



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