Nonprofit Insurance Package Information Form
One Simple Form - takes only 2-3 Minutes!
Your Organization's Contact Info: |
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Your Organization's Name:
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Contact:
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E-Mail (required):
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E-Mail Again (for accuracy):
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Phone:
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Fax (optional):
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Organization Web Address:
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Mailing Address 1:
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Mailing Address 2:
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City:
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State:
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Zip/Postal:
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Your Organization's Underwriting Information: |
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(Don't worry if you are not exactly sure about all of the following information. At this point, simply answer the questions as best as you can.) |
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Describe, in detail, your organization's operations: |
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Date of the formation of the organization: |
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Corporate Form (example
501(c)3, PC or LLC): |
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Current Policies: | Currently Insured by:
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Package
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Workers Compensation
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Automobile
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Professional Liability
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Directors and Officers
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Other
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Current Gross
Revenue:
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Main office/facility:
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Current Annual Payroll:
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Number of Employees:
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List Claims & Amounts Paid
Last Five Years
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Main Location: |
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Street Address 1:
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Street Address 2:
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City:
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State:
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Zip/Postal:
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Building Value of Main Location if owned:
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Contents Value of Main Location:
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Type of Building (wood frame, concrete):
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List of other Tenants in Building
(if less than 5):
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List of Safety Features (fire, burglary, sprinklers etc.):
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List, by address, of all other locations (if any):
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Automobile Information: |
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Do you own or operate any automobiles, vans or trucks?:
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If so, how many of each type:
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