Associations and Not-For-Profit - Moody Insurance Worldwide

Applicant 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 (e.g., Sole Proprietor, Corporation, Partnership, LLC)

Federal ID Number

Type of Business

(Describe typical services performed, customers served, products provided, etc.)

Do you set standards or provide any certifications?

Yes
No

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

General Underwriting Questions

Was the Applicant created by, or now controlled by a governmental agency?

If yes to any of the above, please provide details:

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

Construction

# of Stories

Year Built (approx.)

If over 30 years old, years of updating for

Wiring

Heating

Plumbing

Roof

Square Footage

Owner?

Yes
No

Tenant?

Yes
No

Alarms?

Burglar
Fire
Local
Central Station

Sprinklers?

Yes
No

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?

Yes
No

Exterior Glass?

Yes
No

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?

Yes
No

If yes, for what purposes?

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

Yes
No

Worker's Compensation by State

State

Classification/Duties

Est. Annual Payroll ($)

Number of Employees

Owner/Officer Information

Name

Title

Duties

Incl/Excl

Automobile

Comprehensive Deductible ($)

Collision Deductible

Rented Vehicles used or Employee Vehicles Used in Business?

Yes
No

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?

Yes
No

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?

Yes
No

Would you like an optional Umbrella Quote?

Yes
No

Would you like an Employee Benefits Quote (health, life, disability, long-term care)?

Yes
No

Would you like a Directors and Officers Liability Quote?

Yes
No

Interested in Any Other Coverage Not Shown Above?