LIO Nonprofit & Social Services 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

Named Insured (Legal Name) *

DBA (if different)

FEIN / Tax ID

Year Business Was Established *

Years of Owner / Director Experience *

Primary Contact

Phone

Email Address

Website

Mailing Address

Street Address

Street Address 2

City

State

Zip Code

3. Primary Risk Location

Enter the primary location where operations are conducted. Additional locations may be listed in Section 9.

Same as mailing address

Street Address

City

State *

Zip Code

4. Business Class & Lines of Coverage

Important: The business class you select drives which underwriting questions appear later in this application. Choose the class that best describes the applicant's primary operations.

Business Class *

Describe Applicant's Operations *

Lines of Coverage Requested

Check each line of coverage being requested. Each selection will activate the corresponding coverage details and underwriting questions further in this application.

General Liability (with Products / Completed Operations) Commercial Property Inland Marine (equipment / scheduled property) Sexual Abuse & Molestation Liability Professional Liability Management Liability (D&O, EPL, Fiduciary — sub-coverages selected below) Excess Liability / Umbrella Accident (AD&D / Accidental Medical Expenses)

5. Ineligible Exposures & Declaration

The operations and exposures listed below are ineligible for LIO's Nonprofit & Social Services product. Review carefully, then complete the declaration at the bottom of this section.

Adoption / Foster Care
Adult Day Care
Alumni Associations
Animal Rescue & Adoption
Animal Shelters / Humane Societies
Bar Associations
Big Brothers / Big Sisters
Boy / Girl Scout Organizations (incl. Camp Fire)
Children's Daycare Centers
Churches / Religious Organizations
Correctional Facilities / Reform Schools / Jails
Counseling / Treatment Programs for Sexual and/or Violent Offenders & Abusers
Country Clubs
Equestrian-Based Programs
For-Profit Substance Abuse
Foster Care
Fraternal Clubs
Government Entities
Habitat for Humanity (or similar — construction defect exposure)
Juvenile Detention Facilities
Labor Unions
Medical Exposures
Medical Facilities (not incl. Home Healthcare or Hospice)
Municipalities
New Venture Residential Housing
Nursing Homes / Elder Care / Assisted Living / Senior Care / Continuing Care Retirement Communities
One-on-One Mentoring
Political Groups / PACs / Lobbyists
Research Organizations
Residential Treatment Facilities (Rehab)
Section 8 Low-Income Housing
Senior Housing
Substance Abuse — Inpatient
Substance Abuse — Social and/or Medical Detox
Unions
YMCAs
Zoos, Aquariums & Animal Sanctuaries

Declaration *
The applicant has reviewed the ineligible exposures list above and confirms that the applicant's operations do not include any ineligible class or activity.

Yes — applicant confirms no ineligible exposures No — disclose below

If No — Describe

6. General Liability Coverage

Classification Schedule

When a business class is selected, the schedule below auto-populates with LIO's most common classifications for that class — including the correct ISO premium basis. Fill in the exposure value for each. Remove rows that don't apply, or add custom rows from the full glossary.

Select a business class in Section 4 to populate this schedule.

Code	Classification / Description *	Premium Basis *	Exposure *

71 ISO class codes available

Optional Coverages

Common optional coverages for Nonprofit & Social Services are visible below. Click "Additional optional coverages" for the full list of endorsements available.

Hired Auto & Non-Owned Auto Liability

When checked, related HNOA underwriting questions appear in Section 13.

Stop Gap Employers Liability

BI Each Accident Limit

BI by Disease Aggregate

BI by Disease Each Employee

Employee Benefits Liability

Each Employee Limit

Aggregate Limit

Retroactive Date

Less-Common Sublimits

Assault & Battery Sublimit

Each Occurrence

Aggregate

Snow & Ice Removal Sublimit

Each Occurrence

Aggregate

Other GL Endorsements

Additional Insured Endorsements

List of all Additional Insured Names & Descriptions

7. Commercial Property Coverage

Complete one schedule row per building / location. Attach a separate SOV (Statement of Values) for more than four locations.

Building Label / Address *	Building Limit ($) *	BPP Limit ($)	Year Built *	Construction *	Occupancy

Coverage Options

Valuation *

Cause of Loss *

Coinsurance *

Building Deductible *

Roof Type

Agreed Value

Yes No

Building Updates (year last updated)

Electrical

Plumbing

Roof

Year Last Full Roof Replacement

Aluminum Wiring Polybutylene Piping Asbestos Lead Paint

Were any buildings constructed prior to 1978? (lead-paint exposure indicator)

Yes No

Have any of the above exposures been fully remediated?

Yes No

Describe Remediations

Premises Protection

% of Building Sprinklered

Optional Property Coverages

Business Income Equipment Breakdown Ordinance or Law Utility Services — Direct Damage Utility Services — Time Element Discharge from Sewer / Drain / Pump (Not Flood) Prime Property Enhancement

8. Inland Marine Coverage

Total Limit ($) *

Deductible *

Coinsurance *

Inland Marine Losses (Last 3 Years) *

Scheduled Equipment (provide schedule in attachments)

Description of Property to be Insured

9. Sexual Abuse & Molestation Liability

Note: SAM coverage requires that the applicant have a Formal New-Hire Screening Process and a Written Abuse Policy in place. Underwriting questions in Section 12 will gather the controls in place.

Each Act Limit *

General Aggregate Limit

Coverage Form *

Retroactive Date

Prior and Pending Litigation

10. Professional Liability

Limits

Occurrence Limit *

Aggregate Limit *

Coverage Form *

Retroactive Date

Full Prior Acts

Headcount Exposures (rated per individual)

Enter the number of each professional category the applicant employs or engages. Senior clinical roles (Doctorate Social Worker, Therapist/Nurse Social Worker) only apply to certain exposure types and may not be visible.

Number of Residential Facilities

Number of Doctorate Degree Social Workers

Number of Therapists or Nurse Social Workers

Number of Graduate Degree / MA Social Workers

Number of Counselors or Social Workers

Number of Teachers or Nutritionists

11. Management Liability

Management Liability is a packaged product. Select the sub-coverages requested and provide limits for each.

Sub-Coverages

Directors & Officers Liability Employment Practices Liability (EPL) Fiduciary Liability Violent Episode Coverage

Directors & Officers

D&O Limit *

Retention

Employment Practices Liability

EPL Limit *

Retention

Aggregate Shared with D&O

Fiduciary Liability

Fiduciary Limit *

Retention

Violent Episode

Limit *

Deductible *

Financial & Operational Details (for all ML sub-coverages)

Prior Year Annual Revenue ($)

Current Year Net Income

Prior Year Net Income

Current Year Net Assets

Prior Year Net Assets

Current Year Cash Flow

Prior Year Cash Flow

12. Excess Liability / Umbrella

Occurrence Limit *

Aggregate Limit *

Certified Acts of Terrorism

Excess Coverage Selections

Excess over Professional Liability Excess over Employers Liability

13. Accident Coverage (AD&D / Accidental Medical)

Underwriting will work up Accident coverage details (limits, sublimits, benefit periods, exclusions) with your producer once the submission is reviewed. The single data point needed up front is the number of participants and/or volunteers to be covered annually.

Number of Participants And/Or Volunteers Annually *

14. Underwriting Information

General

Is the applicant a new entity with no prior insurance coverage? *

Yes No

Current / Expiring Carrier *

Expiring Premium *

Is this a mid-term quote, or is coverage currently lapsed? *

Yes No

Is the applicant currently insured by a Surplus Lines / E&S carrier? *

Yes No

Has the applicant been involved in any bankruptcy, criminal, or civil proceedings? *

Yes No

Describe

Has the applicant had insurance denied, cancelled, or non-renewed by an insurer in the last 5 years for a coverage being requested? *

Yes No

Describe

Does the applicant have subsidiaries or affiliated entities?

Yes No

List subsidiaries / affiliates

Has the applicant experienced a loss in the last 5 years for any coverage being requested? *

Yes No

Number of Open Claims *

Describe Losses Claimed or Sustained in the Past 5 Years

Corrective Actions Taken

Applicant Profile

Annual Revenue ($) *

# Full Time Employees *

# Part Time Employees

# Seasonal Employees

Does the applicant utilize signed waivers from clients/participants?

Yes No

Does the applicant utilize independent contractors?

Yes No

Property — Underwriting Questions (auto) N/A

Has the applicant incurred a frozen pipe burst / water damage loss in the last 5 years?

Yes No

Are the applicant's buildings properly winterized with heat maintained to a minimum 50°F (including attics), with notification alerts when temperatures drop below 50°F?

Yes No

Does the applicant have commercial cooking exposure?

Yes No

Is the property designated as a Historical Landmark?

Yes No

Inland Marine — Underwriting Questions (auto) N/A

Does the insured have any individual articles, items, or equipment with value greater than $50,000? (triggered when IM total limit > $50K)

Yes No

Professional Liability — Underwriting Questions (auto) N/A

Does the insured have detailed hiring procedures, including verifying that the applicant's license is current and has never been suspended or revoked?

Yes No

Annual Employee Turnover Rate

%

15. Supporting Documents

Please send the following along with this completed application back to your underwriter. Loss runs are required for ALL coverages requested. The more we have upfront, the smoother the underwriting process!

Required

No loss letters accepted for loss free accounts less than $10,000. 5 years of loss runs required for all others.
Description of operations / overview document or website link

Optional

Form 990 (most recent) and prior 2 years
Audited financial statements (most recent 2 years)
Articles of Incorporation, Bylaws, IRS Determination Letter
Sample participant / client / volunteer waiver (if applicable)
Background-check policy & written abuse policy (required if SAM coverage requested)
Employee handbook & HR procedures (required if EPL coverage requested)
Statement of Values / SOV (required if Property requested)
Equipment schedule (required if Inland Marine requested)
Currently expiring policy declarations page for each line of coverage
ACORD 125 & 126 application forms

Additional Notes for Underwriter

16. Fraud Warning & Declaration

⚠ NOTICE TO POLICYHOLDERS — FRAUD NOTICE (NTC FR01 10/21)

NOTICE TO APPLICANTS: 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 act, which is a crime, and may subject such person to criminal and civil penalties.

NOTICE TO ALABAMA APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be subject to restitution, fines, or confinement in prison, or any combination thereof.

NOTICE TO ARKANSAS, LOUISIANA, RHODE ISLAND, AND WEST VIRGINIA APPLICANTS: 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.

NOTICE TO CALIFORNIA APPLICANTS: For your protection California law requires the following to appear on this form: Any person who knowingly presents false or fraudulent information to obtain or amend insurance coverage or to make a claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.

NOTICE TO COLORADO APPLICANTS: 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.

NOTICE TO DISTRICT OF COLUMBIA APPLICANTS: Warning: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant.

NOTICE TO FLORIDA APPLICANTS: 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.

NOTICE TO KANSAS APPLICANTS: 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 issuance 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 that such person knows to contain materially false information concerning any fact material thereto; or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act.

NOTICE TO KENTUCKY APPLICANTS: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance 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.

NOTICE TO MAINE APPLICANTS: 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 or a denial of insurance benefits.

NOTICE TO MARYLAND APPLICANTS: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who 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.

NOTICE TO MINNESOTA APPLICANTS: A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime.

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

NOTICE TO NEW MEXICO APPLICANTS: 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 civil fines and criminal penalties.

NOTICE TO NEW YORK APPLICANTS: 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 shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.

NOTICE TO OHIO APPLICANTS: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.

NOTICE TO OKLAHOMA APPLICANTS: Warning: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.

NOTICE TO OREGON APPLICANTS: 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, may be guilty of a fraudulent act, which may be a crime, and may subject such person to criminal and civil penalties.

NOTICE TO PENNSYLVANIA APPLICANTS: 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.

NOTICE TO TENNESSEE, VIRGINIA AND WASHINGTON APPLICANTS: 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.

NOTICE TO VERMONT APPLICANTS: Any person who knowingly presents a false statement in an application for insurance may be guilty of a criminal offense and subject to penalties under state law.

I DECLARE THAT THE STATEMENTS MADE IN THIS APPLICATION ARE COMPLETE AND TRUE. The undersigned authorized representative affirms that all information provided is accurate and complete to the best of their knowledge. I understand that coverage is not bound until confirmed in writing by LIO Insurance.

17. Signatures

Applicant / Authorized Representative

Applicant / Authorized Representative Name

Title

Applicant Signature

Signature

Date

Producer / Broker

Producer Name

License Number

Producer Signature

Signature

Date