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 Eric Laughlin, CPIA, Manager, Broker Services, Council Services Plus, at ELaughlin@councilservicesplus.com or call (800) 515-5012 Ext. 128.

Basic Information

Is your non-profit a current paid NYCON member?

Yes

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

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

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

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

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

Are you aware of any fact, circumstance, or situation that may result in a future claim?

Yes

Would you like a quote for a Fiduciary Liability policy?

Yes

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