D&O Form

Applicant Information

Is the organization a non-profit organization with the IRS?

Financial Information

Do you have employees?

Underwriting Information

1. Have there been during the past five years, or are there now pending , any civil, criminal, administrative or arbitration proceedings brought against the organization or any person proposed for this insurance in their capacity as either a director, officer, trustee, employee, volunteer, or staff member of the organization?
2. Is the proposed insured organization aware of any fact, circumstance or situation involving the organization or any proposed insured which he or she has reason to believe might result in a future claim?
3. Does the organization currently have D&O insurance?

Questions / Comments