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"Shaun Irwin has done remarkable things for our agency. He's not only made sure we are protected, he has saved us thousands of dollars over the years and been there to support our agency in both time and money"
Eva Ellis, Southside Services

Quick Quote-
Exclusive program could save your non profit organization up to 37%
Request a Quote for your Non Profit Organization's Insurance Needs. Some information is optional, all quotes are based on what you provide. Please note no coverage is ever bound or implied until confirmed from the Non Profit Insurance Center Office.

Attention: To apply for this program, your organization must have 501(c)(3) status and qualify to be tax exempt.

Information provided on this form will be kept confidential and shared only with affiliate companies for quoting purposes. We respect your privacy, and we will never sell or share this information with any outside parties

General Information

Organization Name:

Contact Name:

Contact Title:

Mailing Address:

City:

State:

Zip:

Phone:

Fax:

Email:

Description of Operations:

Your Website Address:

Federal Employer Number:

State of Incorporation:

Date Organized:

Does organization have any subsidiaries?

yes no

Are Financial Affairs reviewed annually by a CPA?

yes no

Does Organization have tax-exempt status?

yes no

How often does the board meet?

Is attendance required?

yes no

Inquiring about:
(Please check all that apply)

General Liability
Directors and Officers Liability
Crime / Employee Dishonesty Coverage
Property - Building and Contents Coverage
Commercial Auto Coverage
Workers Compensation for Employees / Volunteers

Financial Information

Current Year

Previous Year

Total Assets:

Fund Balance:

Annual Revenue:

Change in Net Assets:
(Excess / Deficit)

Activities of the Organization

Number of Members:

Number of Chapters:

Does the organization publish any magazines or newsletters?
yes no

Is the organization involved in product research, development, testing and/or certification? yes no

Does the organization set standards for the qualification and performance and/or certify its members? yes no

Does the organization engage in any disciplinary actions after peer reviews? yes no

Does the applicant administer or sponsor any insurance programs for its members? yes no

Directors and Officers Liability Coverage

	Insurer	Limit	Deductible	Term
Expiring:
Previous:
Earliest:

Directors and Officer Liability Insurance has been continuously in force since:

Has the Applicant or any person proposed for coverage herein been the subject of, or involved in, any of the following in the past 5 years? (Check if yes)

Anti-trust, copyright or patent litigation?

Any disciplinary action by a regulatory agency/association?

Any action where a license was revoked or suspended?

Any administrative proceeding charging violation of federal or state law or regulation?

Any other criminal actions?

Has the applicant been involved in any of the following in the last 24 months, or does the applicant anticipate being involved in any of the following in the next 12 months? (Check if yes)

Mergers, acquisitions or consolidation with another entity?

Changes in the board of directors or senior management (other than death or retirement)?

Does the applicant direct or request any individual to serve as director, officer, governor or trustee of any other entity?

yes no

Employer Details

Current Number of Employees:

full time

part time

Do you use an employment application for all applicants?

yes no

Do you have an employment handbook?

yes no

How many employees have been terminated or demoted in the past 12 months?

Voluntary

Involuntary

Laid Off

Demoted

Claims Information

Has the applicant been involved in any grievance or other administrative proceeding before any of the following agencies and/or under any of the following acts in the past 5 years:

Natl Labor Relations Board	Fed Labor Standards Act
Fair Labor Standards Enforcement Act	US Dept of Labor
Americans with Disabilities Act	Civil Rights Act of 1991
Age Discrimination in Employment Act	Civil Rights Act of 1964
Equal Employment Opportunity Commission	Other Agency

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The Non Profit Insurance Center, A division of the Anderson Insurance and Investments Agency, Inc.
Toll Free Phone 1-866-710-3030 Toll Free Fax 1-866-810-3030	312 Central Ave SE Suite 392 Minneapolis, MN 55414
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