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AREAS OF SPECIALIZATION
BUSINESS INSURANCE
PERSONAL INSURANCE
EMPLOYEE BENEFITS

Associations and Not-For-Profit

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?
- Accreditation Programs
- Certification Programs
- Development/Administration of Ethics Codes
- Member Peer Review/Disciplinary Actions
- Sponsorship of Insurance Programs
- Standard Setting
- Own or control any political action committees
- Medical treatment at a non-residential facility, residential facility, or third-party medical services
- Counseling or rehabilitation services
- Fund own research and development
- Transportation services for others
- Social media, including blogging or bulletin-board-posting by the public
- Sponsorship or organization of special events
- Publishing, including periodicals, industry resource materials, research papers or other publications
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
Date Format: MM slash DD slash YYYY
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?

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20251 Century Blvd, Suite 425
Germantown, MD 20874
Local: 301-417-0001
Toll-Free: 800-966-0001
Fax: 301-417-0040
customerservice@moodyinsurance.com

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