D & O “Quick Quote” Form Complete the form below and we’ll send you a “quick quote” on a new Directors & Officers Liability policy. Questions? Email Peter Andrew, CEO, Council Services Plus, at pandrew@councilservicesplus.com or call (800) 515-5012 x 125. Basic Information Is your non-profit a current paid NYCON member? Yes No Unsure Organization Name Organization Street Address Street Address Line 2 City State Zip Code Website URL Primary Contact Primary Contact First Name Primary Contact Last Name Primary Contact Title Primary Contact Email Phone Number Liability Information Do you currently have D & O insurance? Yes No Unsure Policy’s expiration date: Date of your nonprofit’s incorporation: Date of your nonprofit’s IRS determination: Brief description of your organization’s services: Do any affiliates or subsidiaries need to be covered under this policy? Yes No Subsidiary name: Current number of employees: Number of employees terminated last year: Number of volunteers (including board members): Using the records from your last fiscal year: Annual Payroll: Annual Revenues: Total Assets: Total Expenses: Total Liabilities: Does your nonprofit do credentialing, accreditation, licensing, peer review or standard setting? Yes No Please indicate if this subsidiary is: Nonprofit For-profit In the last five years have there been any civil, criminal or administrative proceeding brought against the organization, its subsidiaries, board, staff or volunteers? Yes No In the last five years have there been any mergers, acquisitions or similar reorganizations OR are you expecting such in within the next year? Yes No Are you aware of any fact, circumstance, or situation that may result in a future claim? Yes No Would you like a quote for a Fiduciary Liability policy? Yes No Coverage limit requested: $100,000$250,000$250,000 Retirement Plan Information What type of retirement plan does your nonprofit offer? Defined ContributionDefined BenefitEmployee Stock Ownership (ESOP)Excess Benefit Current Plan Assets: Number of Plan Participants: Are you currently working with a representative at Council Services Plus (NYCON’s insurance affiliate)? YesNoUnsure Name of the Council Services Plus representative you have been working with: I understand that pending or prior claims or known circumstances that result in a claim will not be covered under a new D & O policy. After you complete and submit this form you will receive a non-binding “indication” of eligibility, terms and cost. Prior to binding coverage we will require (a) proof of NYCON membership and (b) insurance company application signed by President or Executive Director. “I understand” Contact Information
