Minnesota NonProfit Directors and Officers Coverage Questionnaire
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The Morse Agency
2215 Third Avenue North
Anoka, MN 55303
(800) 557-0550
Fax (763) 421-1622
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Name of Organization
*
Street Address
*
City
*
State
*
Zip Code
Phone Number
*
Fax Number
*
Website
Primary Contacts Name
E-mail
*
Does the applicant entity have 501(c3) status
*
Yes
No
If yes, under what IRSC section?
*
What is the nature of the applicants operation
*
During the last five (5) years, has the organization or any Prospective Named Insureds received any demands for monetary or non-monetary relief, been involved in or had any knowledge of any civil or criminal action, administrative or arbitration hearings
Yes
No
Please Provide Details
Are any of the organizations Directors, Trustees and Officers proposed for this insurance aware of any fact, circumstance or situation involving any Prospective Named Insureds that he or she has reason to believe may result in a claim
*
Yes
No
if "Yes", provide details
How many subsidiaries does the organization have
The organizations total assets as of the most recent year-end
Number of full-time (including Independent Contractors) employees of the organization
Enter the organizations fund balance as of the most recent year-end
Is the organization a current member of MCN
*
Yes
No