IPMG - Application for Non-Profit Organization Liability Insurance

APPLICATION FOR NON-PROFIT ORGANIZATION LIABILITY INSURANCE

1. Insured Information
Applicant Name:
Address:
Address Continued:
City:	State
Zip Code:
Telephone:
Fax:
Contact:
Title:

1.	Name of Organization
		Address

2.	What is the Organization's Structure?
		Date Organized:
		Date Operations began:
		Purpose of Organization:
		State in which incorporated:
3.	Scope of operations:

If organization is regional, list states or areas served:

4.	a.	List any affiliated organizations of which the organization owns more than 50% of the voting stock or appoints more than 50% of the board of directors:

	b.	Does the Organization have any subsidiaries operating for profit? (If yes, please list):

5.	Does the organization have any stockholders or persons who profit from the operations except as salaried employees? (If yes, give details):

6.	a.	Does the organization recieve donations or contributions from the general public?	Yes No
	b.	Are contributions generally solicited?	Yes No
	c.	Of the total contributions recieved, what is the net percentage available for charitable purposes?	%
	d.	If the Organization recieves government funding, what is the percentage of total revenues?	%
	e.	Please provide the following information for the last three (3) years:

Year	Total Revenue	Total Expenditures	Current Fund Balance

7.	Total number of individuals employed by the Organizatoin?
8.	Are any of the Directors, Officers, Trustees, or Employees indebted to the Organization? (If yes, give details):

Part II-Association Details

If the Organization is an Association, please complete this section.

9. Number of chapters:

Number of Members:

10. Publications: Magazines Newsletters Journals

Periodicals Technical Manuals

11. a. Is the Association involved in product testing/certification? Yes No

b. Doest the Association set professional standards or certify it's members? Yes No

c. Does the Associatoin or it's directors, Officers, Trustees, or Employees act as an Administrator of any employee benefit welfare plans under ERISA, or any other fiduciary capacity for any other employee benefit welfare plans? Yes No

If Yes to any of the above, please provide details:

Part III-Governmental Information

12. Within the last three (3) years, has the Organization recieved any inquiry, complaint or notice of hearing from any state or federal regulatory authority or agency or congessional or legislative commitee? (If Yes, give details): Yes No

13. a. Has the Organization filed a Tax Form in the last three years? Yes No

b. If Yes, have the returns been accepted as filed? Yes No

Part IV-Insurance Coverage Information

14. a. Directors and Officers Liability Insurance or Non Profit Organization Liability Insurance carried during the past three years, including expiring policy, if applicable:

Insurer Limit Retention Premium Expiration Date

b. Has any same or similar insurance on behalf of the Organization been declined, cancelled or non-renewed? Yes No

If Yes, please explain:

c. Has the carrier(s) of any same or similar insurance ever been given notice of claim or possible claim by the Organization? Yes No

If Yes, please explain:

d. Does the Organization currently carry General Liability Insurance? Yes No

If Yes, please give carrier and expiration date:

e. The Officer of the Organization designated to receive any and all notices from the Insurer or the authorized representative concerning this insurance is:

Part V-Claim Information

15. Has any claim been made, or is any now pending against the Organization, or any person proposed for this insurance in the capacity of either Director, Officer, Trustee or Employee? (If Yes, give details):

16. Has the Organziation and/or its Directors, Officers, Trustees or Employees been involved in or have any knowledge of pending Federal, State or local actions or proceedings against the Organization and/or it's Directors, Officers, Trustees or Employees? (If Yes, give details)

17. Is any person proposed for this insurance cognizant of any fact, circumstance or situation which said person has reason to suppose might afford valid ground for any future claim against said person and/or the Organization? (If Yes, give details):

If such facts, circumstances or situations exist, any claim or action arising therefrom is excluded from the proposed coverage.

18. The undersigned being authorized by, and acting on vbehalf of, the applicant and all persons or concerns seeking insurance, has read and understands this application, and declares all statements set forth herein are true, complete and accurate. The undersigned further declares and represents that any occurrence or event taking place prior to the inception of the policiy applied for, which may render inaccurate, untrue, or incomplete any statment made herein agrees that the submission and the Insurer's receipt of such report, prior to the inception of the policy applied for, is a condition precendent to coverage.

19. This Renewal application is a supplement to the application(s) attached to the current policy tand said applications together with this Renewal application constitue the complete application which shall be the basis of the contract should a policy be issued and will be attached to and become part of the policy.