LIO Nonprofit Management Liability Application

1. Producer & Submission Info

Brokerage / Agency

Producer / Broker Name

Producer Email

Producer Phone

Desired Effective Date *

Expiration Date *

Quote Type

New Business Renewal

2. Named Insured

Name of Applicant Organization *

Business Type

Name of Individual Submitting this Application

Phone

E-Mail Address *

Website Address

Mailing Address

Street Address *

Street Address 2 (Suite, Unit, etc.)

City

State

Zip Code

3. Address of Applicant's Primary Location

Same as mailing address

Street Address

City

State

Zip Code

Jurisdiction State *

4. Description of Operations

Description of Operations *

Organizational Scope Is *

Local In Nature Regional/National International

When Was the Organization Established? *

Is the applicant organization acknowledged by the IRS as a non-profit organization, or has an application been made to the IRS? *

Yes No Application Pending

Please Check All of the Following Which Your Organization Does

Research / Development / Testing Certification / Accreditation / Standard-Setting Disciplinary Actions Administration / Sponsorship of Insurance Programs Collective Bargaining

5. Financial Info

Total Annual Revenue ($) *

Prior Year Annual Revenue ($) *

6. Organizational Changes & Risk History

In the next year (or the past 2 years), is the organization anticipating or has had any of the following:

Any merger, acquisition or divestiture? *

Yes No

Any facility/branch location closings or layoffs? *

Yes No

Any creation of new organization or subsidiary? *

Yes No

Has the organization been subject to any workplace violent incidents in the past 5 years? *

Yes No

7. Subsidiaries & Chapters

Does the organization have subsidiaries/chapters that are contemplated for coverage on the policy for which the organization is applying? *

Yes No

The answers to Section 8 (Chapters/Members/Volunteers) and Section 9 (Employees) below should include subsidiaries and chapters contemplated for coverage under the policy for which the organization is applying.

8. Chapters, Members & Volunteers

Number of Chapters

Number of Members

Number of Volunteers

9. Number of Employees

Provide employee counts as of the date this application is signed, and as of one year prior to the date this application is signed.

	Full Time Employees	Part-Time Employees	Seasonal Employees
As of the date this application is signed
% of Employees Involuntarily Terminated in the Past Year?

10. Employment Practices & HR Policies

Does the insured have the following procedures/policies in place:

Anti-Discrimination *

Yes No

Anti-Sexual and Anti-Harassment *

Yes No

Employee Handbook/Application *

Yes No

Annual Written Evaluations/Performance Reviews of Employees *

Yes No

Employee Complaint Resolution *

Yes No

11. Fiduciary Plans

Please list all fiduciary plans (e.g., 401(k), pension, health & welfare). Add a row for each plan.

Full Name of Plan	Current Asset Value	Latest Annual Contributions	Current # of Participants	Current Plan Status

For all retirement plans, is an outside investment firm utilized?

Yes No Not Applicable

12. Prior Acts, Claims & Circumstances

Within the past five years, has the applicant or any person proposed for coverage (whether or not in the service of applicant) been the subject of or been involved directly or indirectly in any civil, criminal, regulatory, legislative or administrative proceeding(s)? *

Yes No

Within the last five years, has any inquiry, complaint, notice of hearing, claim or suit been made against any entity proposed for insurance, or any person proposed for Insurance in the capacity of director, officer, trustee, employee or volunteer of any entity proposed for insurance? *

Yes No

Is any person(s) proposed for this Insurance aware of any fact, circumstance or situation which may result in a claim against any entity proposed for insurance or any of its directors, officers, trustees, employees or volunteers? *

Yes No

Has any previous insurer of the applicant organization for directors and officers or employment practices liability ever refused to renew the Applicant's policy? *

Yes No

13. Current Insurance Status

Please indicate your current insurance status for each of the following items.

Coverage Line	Current Insurer	Limit of Liability	# of Current Years Continuously Insured	# of Claims/Potential Claims Reported (Past 5 Yrs)
Directors & Officers Liability
Employment Practices Liability Check if same as D&O
Fiduciary Liability Insurance Check if same as D&O

Premium for the Policy Described Above ($)

14. State Mandatory Fraud Warning Statements & Declaration

⚠ STATE MANDATORY FRAUD WARNING STATEMENTS

AL: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

AR: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

CO: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.

DC: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

FL: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.

KS: Any person who, knowingly and with intent to defraud, presents, causes to be presented or prepares with knowledge or belief that it will be presented to or by an insurer, purported insurer, broker or any agent thereof, any written, electronic, electronic impulse, facsimile, magnetic, oral or telephonic communication or statement as part of, or in support of an application for the insurance of, or the rating of an insurance policy for personal or commercial insurance, or a claim for payment or other benefit pursuant to an insurance policy for commercial or personal insurance which such person knows to contain materially false information concerning any fact material thereto; conceals, for the purpose of misleading information concerning any fact material thereto commits a fraudulent insurance act.

KY: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.

LA: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

MD: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

ME: It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines, and denial of insurance benefits.

NJ: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties. Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties.

NM: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

NY: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties not to exceed five thousand dollars and hte stated value of the claim for each such violation.

OH: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.

OK: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony.

OR: Any person who knowingly and with intent to defraud or solicit another to defraud the insurer by submitting an application containing false states as to any material fact may be violating state law.

PA: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.

RI: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

TN: It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits.

VA: It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits.

WA: It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits.

WV: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

IMPORTANT NOTICE – DECLARATION

I DECLARE THAT THE STATEMENTS MADE IN THIS APPLICATION ARE COMPLETE AND TRUE.

Any person who, with the intent to defraud or knowing that he or she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement may be guilty of insurance fraud and subject to fines and/or imprisonment.

As part of our underwriting procedures, a routine inquiry may be made to obtain applicable information concerning character, general reputation, and credit history. Upon your written request, additional information as to the nature and scope of the report, if one is made, will be provided.

This application is the basis for the policy, if issued, and becomes part of the policy.

15. Signatures

Applicant

Applicant Name

Title

Signature of Applicant *

Signature — must be signed by the President, Chairman, or Executive Director

Date

Producing Agent

Agent Name

Agent Address

Signature of Producing Agent

Signature

Date