Non-Profit Insurance Application

General Liability Supplemental Application

Applicant Information
General Information
Special Events/Fundraisers
Foster Homes
Premises
Animals
Other
Signature

General Information

Applicant Name

Contact Person

Title

Primary Phone Number

Fax Number

Check here if none available

None

Website/URL

Check here if none available

None

Billing Address

Address Line 1

Apartment/suite #

City

State/Province

Zip/Postal

Quote Need by Date

Proposed Effective Date

Limits Requested:

FEIN #:

General Information

Does Applicant currently have any General Liability coverage in force?

Yes

If yes, please submit currently valued loss runs for the past three years and complete the following:

Prior Carrier

Effective Date

Limit

Premium

Retro Date (If claims made)

Is the Applicant a tax-exempt nonprofit organization under the U.S. Internal Revenue Code 501(c)(3), or in the process of obtaining this tax-exempt status?

Yes

Pending

If pending, please attach a copy of their application and check to the IRS confirming they’ve applied.

Maximum file size: 25MB

If no, stop. We can only write insurance for tax-exempt 501(c)(3) organizations.

If name on letter from Dept. of Treasury conferring 501(c)(3) status differs from name of Applicant, please explain:

In what State is the Applicant incorporated?

What is your principle operating State?

If not incorporated, please explain:

Complete the following:

Annual Budget

Annual Payroll

Annual Sales

Number of Employees

Number of Volunteers

Non-Profit Insurance Application