Business Type *
Limits of Liability *
Do you currently have insurance? *
If "Yes", what type? *
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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? *
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?
Is Workplace Violence coverage desired?
Is Internet Liability desired?
How did you hear about us? *