Non-Profit Insurance Quote Request |
ABOUT THE ORGANIZATION |
Organization Name:
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First Name:
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Last Name: |
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Address: |
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City: |
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State: |
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Phone: |
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Zip Code: |
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E-mail: |
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Confirm E-mail: |
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ABOUT THE NON-PROFIT ORGANIZATION |
Name
of Organization: |
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Business Structure: |
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Description of your
activities and/or your membership: |
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Year Started: |
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Tax ID #: |
(if available) |
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What types of
insurance are you seeking? Choose as many as you need. |
#1:
#2:
#3:
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How many members does your group have per year (average): |
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Fill out the sections
below for the types of quote that you are seeking |
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Directors & Officers and
Employment Practice Liability Insurance SECTION
These are generally offered as a package to
non-profit groups. |
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Directors and
Officers Liability Limits: |
$
($250,000 will be quoted if nothing is entered) |
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Tell us about
your directors and officers: |
Full Time Employees: |
(enter a number or write 0)
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Part-Time Employees: |
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Full Time Volunteers: |
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Number of Board Members: |
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How many counselors work at
your group: |
(if known) |
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Gross Receipts: |
Prior Year $
(if new business, write NEW) |
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Current
Year $
(estimate if needed) |
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Estimates for Next
Year $
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Annual Payroll: |
$
(if none, write "none") |
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Operating Fund Balance: |
$ (if
available) |
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Claims: |
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COMMERCIAL GENERAL LIABILITY SECTION - OPTIONAL |
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General Liability Limits: |
$
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Space Occupied (sq feet): |
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Building Security System? |
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Number of annual events: |
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PROPERTY INSURANCE -
OPTIONAL |
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Business personal property
and equipment? |
(office equipment, supplies, furniture) (we can quote
coverage for inventory and food spoilage based on your industry) |
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Year Building Built: |
(estimate is
acceptable) |
Building Insurance? |
(tenant improvement coverage, or for the building) |
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*** |
Do you currently have insurance (if
yes, with what carrier)?
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Current Premium:
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Do you have any other information
about your organizations, or comments that you would like to
share? Please place special requests here, such as extra coverage
for special items. |
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NO COVERAGE IS BOUND,
OFFERED, ISSUED THROUGH THIS ELECTRONIC COMMUNICATION, ALL POLICIES MUST BE
UNDERWRITTEN AND APPROVED BY THE CARRIER. DO NOT CANCEL YOUR CURRENT
INSURANCE. |
Copyright 2012 Stratum
Insurance Agency, LLC |
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