| Personal Information |
| First Name
Required
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| Last Name
Required
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| Formal Name of Business
Required
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| Is this a non-profit organization?
Required
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| Business Type
Required
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| Street
Required
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| City
Required
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| State
Required
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| ZIP / Postal Code
Required
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| Primary Phone Number
Required
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| E-Mail Address
Required
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| Website Address:
Required
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| Does the applicant want any subsidiaries covered?
Optional
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| If yes, provide name of company, % owned by applicant, address and description of operations.
Optional
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| Is the applicant a subsidiary of another organization?
Required
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| Name of parent and address:
Optional
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| FINANCIAL INFORMATION |
| Total Current Assets
Optional
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| Total Current Liabilities
Optional
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| Total Debt
Optional
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| Current 12 month annual gross revenues
Optional
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| Total annual income or (loss)
Optional
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| EMPLOYEE COUNT |
| Full-time employees
Required
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| Part-time
Required
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| Temporary/Seasonal
Required
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| Independent Contractors
Required
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| Leased employees
Required
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| How many of the above are located in California?
Required
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| How many of the above are located in Florida?
Required
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| How many of the above are located in Louisiana?
Required
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| How many of the above are located outside the USA?
Required
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| DIRECTORS AND OFFICERS SECTION |
| Please list all shareholders by name that own greater than 10%, with % owned and advise if they are a Director or Officer..
Optional
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| Have there been any changes in the board of directors or senior management in the past three years for reason other than expiration of term, death or retirement?
Required
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| Has the applicant changed outside auditors in the last three years?
Required
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| Have the auditors found any material weaknesses in applicants system of internal controls?
Required
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| Has the applicant violated or breached any debt covenant, loan agreement or other material obligation in the past three years?
Required
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| Has the applicant, in the past 36 months, completed or agreed to a merger, acquisition or consolidation with another entity?
Required
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| Has the applicant, in the past 36 months, completed or agreed to a sale, distribution or divestiture of more than 25% of assets of stock of the organization?
Required
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| Has the applicant, in the past 36 months, completed or agreed to any registration for a public offering?
Required
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| Has the applicant, in the past 36 months, completed or agreed to any private placement?
Required
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| Has the applicant, in the past 36 months, completed or agreed to any reorganization or formal arrangement with creditors?
Required
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| Has the applicant or any person proposed for coverage (whether or not in the service of applicant) been the subject of or been involved directly or indirectly in any civil, criminal, regulatory, legislative or administrative proceeding(s)?
Required
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| EMPLOYMENT PRACTICES LIABILITY SECTION |
| Do more than 50% of all employees currently earn more than $100,000?
Required
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| Has any entity proposed for insurance downsized, laid off, or reduced staff in the past 12 months or anticipate doing so in the next 12 months?
Required
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| If “Yes,” what percentage of the workforce was/will be affected?
Optional
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| WRITTEN GUIDELINES REQUIREMENTS |
| Does each entity proposed for insurance have a written email/internet policy currently in place or is willing to implement one within 21 days of binding
Required
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| Does each entity proposed for insurance have a written anti-discrimination and anti-harassment policy currently in place?
Required
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| Plans offered by applicant:
Required
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Hold down the Ctrl Key to make multiple selections. |
| If a plan is offered, provide name of plan, type of plan, what are the current plan assets and # of participants.
Optional
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| If a 401k plan is offered, does each 401K plan allow the participants to select from at least three investment options and to monitor the performance of each selection?
Optional
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| Are 401k participants advised of the performance of their investment options and given the opportunity to adjust their selections at least annually?
Required
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| Does each plan subject to ERISA (Employee Retirement Income Security Act) comply with all applicable requirements of ERISA and the Internal Revenue Code of 1986, as amended (the “Code”) including eligibility, participation, vesting, fiduciary standards?
Optional
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| Has each plan been reviewed to ensure that there are no violations of any plan document or of the ERISA and “Code” prohibited transactions?
Required
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| Within the past 18 months, has an actuary found that any plan was or is currently under-funded by more than 10%?
Required
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| LOSS INFORMATION |
| Within the last five years has any employment related, third party harassment or third party discrimination claim, suit, inquiry, complaint or notice of hearing been made against the applicant or any individual proposed for insurance?
Required
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| Within the last five years, has any claim, suit inquiry, complaint or notice of hearing been made against the applicant or any person proposed for Insurance in the capacity of director, officer, or employee of the applicant?
Required
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| Is any person or entity proposed for this Insurance aware of any fact, circumstance or situation which may result in a claim against the applicant or any of its directors, officers or employees?
Required
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| If yes, please explain:
Optional
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| Within the past five years, has any claim been made or is any claim now pending against any plan, organization or individual proposed for this insurance in the capacity as a fiduciary, trustee or administrator?
Required
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| If yes, please explain:
Optional
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| Is any person or entity proposed for this insurance aware of any fact, circumstance, situation or ERISA violation which may result in a claim that may fall within the scope of the proposed Insurance?
Required
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| If yes, please explain:
Optional
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| How did you hear about us?
Optional
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| Additional Comments
Optional
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Submission Validation Required |
Enter the Validation Code from above.
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