D & O Quote Request

NONPROFIT ASSOCIATION DIRECTORS AND OFFICERS PROFESSIONAL LIABILITY INSURANCE RAPID-RATE INDICATION SHEET

NAMED INSURED

CONTACT NAME

TITLE

MAILING ADDRESS

CITY STATE ZIP CODE

PHONE NUMBER FAX NUMBER

DESCRIPTION OF OPERATIONS

IS THE ORGANIZATION A TAX EXEMPT 501 (C) 3 ORGANIZATION ?
YES NO

TOTAL NUMBER OF EMPLOYEES DATE OF INCORPORATION

ANY PRIOR OR PENDING LITIGATION ? YES NO

IF YES, PLEASE PROVIDE DETAILS

TOTAL ANNUAL REVENUES $

CURRENT DIRECTORS AND OFFICERS COVERAGE:
INSURER LIMIT $

RENTENTION $ PREMIUM $

EXPIRATION DATE RETRO/PRIOR ACTS DATE

FIDUCIARY LIABILITY
IF CHECKED TOTAL PLAN ASSETS $

PUBLISHER LIABILITY
REQUEST PUBLISHERS LIABILITY APPLICATION

EMPLOYMENT PRACTICES LIABILITY

SPECIAL TERMS