Nonprofit Insurance Quote Request

General Information...
 
Has Coverage Ever Been Declined?

Check which type(s) of coverage you desire *

APPLICATION SECTIONS
(please complete coverage section desired)
If question is not applicable, please indicate "N/A". If answer is unknown, please indicate "UNK".

 

Property and Liability Coverages

I am also interested in...
Terrorism Insurance is AUTOMATICALLY INCLUDED - If coverage is not desired, please indicate.

If Age>20 Years, Date of Renovation:
Fire Hydrant
Sprinklers
Burglar Alarm
Fire Alarm
Boilers on Premise


Inland Marine

Computer Equipment:


Tools & Equipment Schedule:

Crime

Employee Dishonesty:
 
Forgery:
 
Computer Fraud:
 
Funds Transfer:
 
Theft Disappearance and Destruction: (Money & Securities)
 
Deductible
 
Safe:
 
Audit Done By:
 
Are bank accounts reconciled by someone not authorized to deposit or withdraw?

Automobile

Policy Coverage
Coverage            _____      
  Liability
  PIP (no fault)
  OBEL
  Med Pay
  Uninsured Motorist
  Underinsured Motorist
  Hired & Non-Owned
 .
Limit                 
$1,000,000
$150,000
$25,000
$10,00
$1,000,000
$1,000,000
$1,000,000 
Garaging Location:

Garaging Location:


Garaging Location:

Drivers must have the type of license required by their states for the vehicles operated.
Please answer the following questions regarding motor vehicle violations occurring in the past three years (unless otherwise noted).
Has any drivers' license been suspended or revoked?
Has any driver been arrested for... (see below)
  • Driving while intoxicated, or under the influence of alcohol or drugs?
  • Reckless driving or similar violations (e.g., racing)?
  • For speeds more than 25 mph over the posted limit?
  • For criminal type convictions (e.g. negligent homicide, manslaughter, hit & run)?
  • Driving without a license?
  • Failure to report an accident or making a false report to authorities?
Has any driver had three or more at fault accidents and/or moving violations in the past three years?
Has any driver had two or more at fault accidents and/or moving violations in the past three years?

Cyber Liability

Do you have a firewall?
Do you enforce a software update process?
Do you have a virus protection program in place?
Do you control access to your computer systems?
Do your access control procedures address access to critical and sensitive computer systems?
Do you have a person or group responsible for info security?
Do you have a program in place to periodically test your security controls?
Do you outsource a critical part of your internal network or
computer system or internet access or presence to others?
Do you allow employees to download personally identifiable information
of customers or confidential information in your care belonging to third
parties onto laptops or other storage media?
If yes, is the information required to be encrypted when it is stored
onto the laptop or other storage media?
Does your hiring process include criminal background checks?

Workers' Compensation

Employers liability limits 100/500/100 unless otherwise indicated


COVERAGE INCLUSIONS/EXCLUSIONS:
Are officers included or excluded?

Statutory Disability

Umbrella

Provides excess liability coverage over a primary or underlying liability policy(ies).


ADDITIONAL INFORMATION:
Does your organization do any of the following?
Provide any regulatory, inspection, certification, accreditation,
setting or reviewing standards of similar services?
Engage in lobbying or political action?
Provide any type of medical or health related services?
Do you own or manage any property other than offices and contents?
Provide any counseling, support, intake, referral services, crisis intervention,
hot lines or other direct client services?
Conduct any special events or fund raisers off premise?

Disclaimer Notice - The premiums quoted are estimates based on information you provided. This quotation does not constitute a contract of insurance, nor does it provide coverage for any loss or claim. Further information may be required in order for a complete quote to be provided. This quote request contains some information about coverage offered but it does not list all of the conditions and exclusions that apply to the described coverage. The actual wording of the policy governs all situations.

This is not an “Application” for insurance.  We ask that you provide general quote request information on this online form for the purposes of gathering general information on your interest in our insurance products and services.  A Marshall & Sterling representative will be in contact with you shortly to discuss the formal application process.