Wisconsin Nonprofit Mangement Liablity Coverage Questionnaire

Name of Organization*

Street Address*

City*

State*

Zip Code

Phone Number*

Fax Number

Website

Primary Contacts Name*

E-mail*

Does the organization currently have Directors and Officers Liability Insurance* Yes
No

Current Insurance Carrier

Expiration Date

Limit of Liability

Deductible

Premium

Does the organization have 501(c3) status* Yes
No

What is the nature of your operations?*

If "Yes", under which IRSC section*

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 organizations have

The organizations total assets as of the most recent year-end

Enter the organizations fund balance as of the most recent year-end*

Number of full-time (including Independent Contractors) employees of the organization

Please feel free to contact us with any additional quesitons.