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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Type of Organization: |
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Your mission statement or
information on your goals. |
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DETAILED Description of your
activities and/or your membership: |
You must provide a detailed
description of exactly what services your offer, special events you
will hold, and any additional information that you can share. Please
check your email shortly after you complete this form, because we
will likely send you more questions. |
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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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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
(We will quote professional liability as part of
this, when available) |
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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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Do you belong to
any trade or professional associations? |
(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 2016 Stratum
Insurance Agency, LLC |
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