Directors and Officers Insurance for Private CompaniesProducer InformationBusiness or Non-Profit NameYour Name First Last Email Address Enter Email Confirm Email We can use this to contact you with questions or send a quote.Phone NumberInformation We Need to Get a QuoteAddress Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code For Profit or Non-Profit*For Profit (Private Company)Non-ProfitFor Profit (Public Company)Fund Balance ($)Number of Board Members - VOLUNTEERSNumber of Board Members - PAID (people who are compensated to be the boardNumber of Full Time EmployeesIf you have none, just write "none"Number of Part Time EmployeesIf you have none, just write "none"Total Payroll to all employees (if any)Please write either an amount or "none"Description of Operations and any other information that you want to provideWe need a description of the services that your business or non-profit provides.Does the applicant have any of the following? Current Insurance (in force) Prior Claims (Closed) Open Claims Negative Fund Balance Knowledge of a potential incident that may result in a claimName of prior carrier, retroactive date, and in force limitsAre you interested in adding Fiduciary Liability?NoYesFiduciary liability is important if you manage funds any benefits plans, retirement plans, group life insurance, cash plans, or related plans.If you also want Fiduciary Liability answer this questions: How much money is under management (in 401k or retirement accounts)?If you manage any benefits, group life, medical expense plans, or pension and retirement plans, you should consider purchasing this coverage.Limits of insurance that you are requesting$500,000$1,000,000$2,000,000$3,000,000$4,000,000$5,000,000More than $5,000,000In many cases, you will see several options on the quotes. If available, quotes will include separate limits of coverage for directors and officers insurance and/or employment practices liability insurance.Do you have an application or loss runs that you want to upload?Δ
