Directors & Officers Quote Form
Fill out the following form as completely as possible. Once you have completed the form, click the Submit button to send your information. Your request will be handled promptly.
Contact Information
State *
General Information
Business Type *
Limits of Liability *
Do you currently have insurance? *
If "Yes", what type? *
Hold down the Ctrl Key to make multiple selections.
Expiration Date
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Detail description of operations *
Directors' Name & Position *
Officers' Name & Position *
Do you have a tax-exempt status under the U.S. Internal Revenue Code? *
Do you publish any magazines, periodicals or newsletters? *
Are you involved in product research, product development, testing and/or certification? *
Do you set standards for the qualification and performance and/or certify your members? *
Do you engage in any disciplinary actions as a result of peer review activities? *
Do you administer or sponsor any insurance programs for your members? *
Financial Information
Previous Year
Current Year
Directors & Officers
Within the last 5 years, has any claim or suit been made against a Director, Officer, Employee, or Volunteer? *
Are you aware of any fact, circumstance or situation which may result in a claim? *
Do you provide services for persons under the age of 18? *
Employee Practices - Optional
# of Employees 1 Year Ago
# of Employees Currently
Do you have an employment handbook?
Do you use an employment application for every potential employee?
Do you have an "At Will" provision in the employment application or handbook?
Have you implemented an anti-sexual harassment policy?
Do you use outside employment counsel for employment advise?
Additional Coverages
Is Workplace Violence coverage desired?
Is Internet Liability desired?
Additional Information
How did you hear about us? *
Important NoticeAny
submissions or payments made via this website do not constitute a
binding agreement to your policy or coverages. Changes and
payments to policies are not effective or binding until you, or any
party involved, receive official notice from either your insurance agent,
or your insurance company. If you have any questions, please feel free to
contact us. Per the terms of our
online privacy policy we will not resell your information to any third-party.
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