Minnesota Management Liability Coverage Questionnaire

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

Please feel free to contact us with any additional quesitons.