Moody Insurance

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Associations and Not For Profit Company Insurance Questionnaire

General Application Information

(Required *)

Complete Business Name: *

Mailing Address/Street:

City/State/Zip:

Location Address/Street (if different from mailing):

City/State/Zip:

Primary Contact Name: *

Contact Title:

Phone Number: *

Fax Number:

Email Address: *

Web Site Address:

Type of Entity
(Sole Proprietor, Corporation, Partnership, LLC, etc):

Federal ID Number:

Type of Business:
(Describe typical services performed, customers served, products provided, etc.) :

Do you set standards or provide any certifications?

No Yes

Do you utilize volunteers? In what function, how many and how often?

Do you have any foundations or for-profit ventures? Are these operating under another separate entity name?
Please describe operations and relationship to the main organization:

Years In Business:

If New Venture, prior experience:

Do you work or sell product overseas?

Yes No

Do you have a board of directors?

Yes No

Describe special events you hold:
(annual conference, fundrasing activities, etc.)

Do any of these events generate a large amount of income for your organization that, if cancelled, would cause a significant loss of money in unreimbursable expenses?
If this applies to you, please describe:

Current Insurance Information

Current Insurance Carrier (Name of Insurance Company):

How Long Insured:
Date(s) Policy(s) Expire:
Reason for Seeking New Carrier:

Location / Building Information

LOCATION 1

LOCATION 2

LOCATION 3

Construction:

# of Stories:

Year Built (approx.):

If over 30 years old, years of updating for

Wiring
Heating
Plumbing
Roof

Square Footage:

Owner?

No Yes

Tenant?

No Yes

Alarms?

Burglar
Fire
Local
Central Station

Sprinklers?

No Yes

Coverage/Rating Basis Information

Property

Replacement Value of Contents:
Should include Leasehold Improvements(may also be included in building so obtain a breakdown), Leased Property, Inventory, Furniture/Fixtures, Equipment, Printed Materials, Consumables, Property of Others

Replacement Value of Building, if applicable:

Replacement Value of Computer Hardware:

Valuable Papers:

Accounts Receivable:

Other property or equipment (specify what):

Business Property Used/Transported/Stored Off-Premises:

Exterior Sign?

No Yes

Exterior Glass?

No Yes

Business Income:

General Liability

Each Occurrence Limit Desired:

Estimated Annual Gross Receipts:

Estimated Annual Total Payroll

Number of Full Time Employees:
Number of Part Time Employees:

Do you use sub-contractors?:

No Yes

If yes, for what purposes?:

Do you require sub-contractors to carry insurance and do you obtain certificates of insurance?:

No Yes

Worker's Compensation by State

State	Classification/Duties:	Est. Annual Payroll:	Number of Employees:
		$
	Classification/Duties	Est. Annual Payroll:	Number of Employees:
		$
	Classification/Duties	Est. Annual Payroll:	Number of Employees:
		$
	Classification/Duties	Est. Annual Payroll:	Number of Employees:
		$

Owner/Officer Information

Name	Title	Duties	Incl/Excl

Name	Title	Duties	Incl/Excl

Name	Title	Duties:	Incl/Excl

Name	Title	Duties	Incl/Excl

Automobile

Comprehensive Deductible:

Collision Deductible:

Rented Vehicles used or Employee Vehicles Used in Business?

No Yes

If yes, number of rental car days/year:

If non-owned, how many employees drive their cars frequently for company business:

If any key employees have company vehicles and do not buy a personal auto policy for their protection while driving for personal use (Drive Other Car Coverage ), list their names:

Owned Vehicle Schedule
NOTE: You may complete with Vehicles and Drivers below, or fax us your list at 301-417-0040

YEAR	MAKE / MODEL	COST NEW	GARAGING CITY/STATE	RADIUS	USE in YEARS

Drivers Schedule (if you own vehicles)
(List all employees who drive any vehicle on company business).

NAME	DATE OF BIRTH	DRIVERS LIC #	STATE	ACCIDENTS/VIOLATIONS WITHIN LAST 3 YEARS

Prior Claim/Loss Information

Have you had any prior claims or losses? No Yes

IMPORTANT: IF YOU ANSWERED YES ABOVE, PLEASE CALL YOUR CURRENT AGENT AND REQUEST A COPY OF YOUR CLAIMS HISTORY (OR “LOSS RUNS”) FOR THE LAST THREE YEARS FOR ALL OF YOUR POLICIES.

Other Optional Coverage to Consider
Do you need coverage for trips or work outside the United States?	No Yes
Would you like an optional Umbrella Quote?	No Yes
Would you like an Employee Benefits Quote (health, life, disability, long-term care)?	No Yes
Would you like a Directors and Officers Liability Quote?	No Yes
Interested in Any Other Coverage Not Shown Above?

©2012 MOODY INSURANCE WORLDWIDE
20251 Century Blvd | Suite 425 | Germantown, MD 20874
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