Nonprofit Insurance Application

Basic Information

Organization Name *

Mailing Address *

Mailing City, State & Zip *

Location Address
(if different than mailing)

Location City, State & Zip

Contact Name *

Phone *

Email *

Website

Years in Business *

Current Insurance Company *

Expiration Date

Description of Operations *

Operations Information

Annual Budget *

Annual Payroll *

Annual Receipts *

Total Assets *

Please specify major funding sources and percentage of budget:

Private Foundations

Gifts & Donatons

Fundraising Events

City, State & Federal Grants

Other Grants

Fees for Servcies

All Other Sources

Number of Students Served per Year (if any) *

Number of Clients/Customers per year (if any) *

Number of Full Time Employees *

Number of Part Time Employees *

Approximate Number of Volunteers *

Do you have a Volunteer Accident Policy in Place? *

Yes
No

Do you have a Student/Participant policy in place? *

Yes
No

Are you a member of any professional organization or association? *

Yes
No

If yes, please provide details

Are you required to be licensed or accredited? *

Yes
No

If yes, please provide details

Has your license ever been suspended or revoked? *

Yes
No
N/A

Have you ever been subject to a hearing regarding your operations? *

Yes
No

If yes, please provide details

Are there any services or operations not stated in this application? *

Yes
No

If yes, please provide details

Do you have any Special Events or Fundraisers? *

Yes
No

If yes, please provide details (type and approx number of people)

Service & Activity Information

Do you have an orientation program for Staff and/or Volunteers? *

Yes
No

If yes, does it include any of the following?
(check all that apply) *

Review of the Organization's policies
Training in emergency procedures and first aid
Review of child abuse and neglect laws
Review of job responsibilities
Recognition of childhood diseases
Background checks required
N/A

Do you organize or sponsor rallies or demonstrations? *

Yes
No

Do you publish books or periodicals? *

Yes
No

Do you provide any counseling services? *

Yes
No

Do you provide medical services? *

Yes
No

Do you provide a referral, legal aid and/or computer services? *

Yes
No

Do you take your clients and/or students on Field Trips? *

Yes
No

If yes, please provide details on number of trips, types of destinations & type of transportation

Do you have a swimming pool? *

Yes
No

Do you provide housing or lodging? *

Yes
No

Does your organization own any vehicles? *

Yes
No

Do Employees or Volunteers use their own vehicles on your behalf? *

Yes
No

Do you require Employees and/or Volunteers to provide Proof of Insurance? *

Yes
No
N/A

If so, what limits are required?

Total Number of Employees who use their own vehicles

Total number of volunteers who use their own vehicles

Coverage Specifics

Liability Limit Desired *

Other coverage you want quoted:

Social Services Professional Liability
Improper Sexual Conduct
Directors & Officers
Employment Practices Liability

Comments & Questions