Directors & Officiers Application Applicant Non-Profit Association InformationAssociation Name Association Mailing Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Physical Address Same as Mailing Address? Yes Association Physical Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email Fax Number Association TypePlease select one of the following: Condominium Homeowners Association Cooperative Commercial/Business Community Association Timeshare (interval) Association Master Association Other If "Other", please specify: Does entity have a property manager? Yes No Property Manager InformationProperty Manager Information (if applicable)Company Name Property Manager Mailing Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Check if same as association physical address: Yes Property manager email Property manager fax Website(if applicable) Association Liability (D&O) Underwriting InformationProposed effective date? Month Day Year Date association established? Month Day Year Number of units in the entity currently built?Is association still being built? Yes No If yes, date completion expected? Month Day Year Total number of units at build out?Name of the developer Does the developer have more than 50% representation of the Board of Directors? Yes No Commercial occupancy?(other than the office of the Property Manager) Yes No If yes, percentage of commercial occupancy: Describe the type of other commercial occupancy:Are any of the units part of a rental pool? Yes No If yes, percentage of commercial occupancy? Does the association have armed security services or an armed neighborhood watch person? Yes No Financial InformationPlease provide the following financial information for the Applicant and its Subsidiaries:Date of Financial StatementCurrent YearPrior YearTotal AssetsCurrent YearPrior YearTotal LiabilitiesCurrent YearPrior YearFund BalanceCurrent YearPrior YearTotal RevenuesCurrent YearPrior YearNet Income or Net LossCurrent YearPrior YearSubsidiariesProvide the following information on all subsidiaries of the insured organization.If "None", check here: None Add as many subsidiaries as needed.Subsidiary NameNature of Business% Owned by Insured OrganizationDate Created or Acquired ExposuresDoes the association have any of the following exposures?Please note that the association may not be eligible for the program and/or additional underwriting information may be required. None Nightclub/Bar Liquor Store Church Daycare School Hotel Airstrip/Hangers Government/Political Offices Hospitals/Healthcare Clinics (other than doctor's office) Water/Sewage Treatment Does the entity have a positive fund balance?If the fund balance is negative, please include financials and an explanation. Yes No Has there been an assessment increase or special assessment in the last 12 months or pending? Yes No If yes, what percentage was assessment increase? Total amount of special assessment? Are greater than 20% of unit owners more than 90 days delinquent on association dues? Yes No If yes, what percentage? Have any government fines of fees been assessed in the last 2 years? Yes No Is the average unit of value in excess of $1,000,000? Yes No Is the association an "Over 55" community? Yes No Number of entity employees? Does the association have an employee manual or handbook? Yes No How many of the following amenities or recreational facilities does the association have and/or manage?Check all the apply. None Sport Courts Pools/Spas Lakes/Ponds Playgrounds Fitness Rooms Community Centers/Rooms Golf Courses Docks Marina Diving Boards Pool Slides # of Sport Courts # of Pools/Spas # of Lakes/Ponds # of Playgrounds # of Fitness Rooms # of Community Centers/Rooms # of Golf Courses # of Docks # of Marinas If Marina exists, are fuel services provided? Yes No # of Diving Boards # of Pool Slides Does the association provide or contract with a third party to provide beachfront or on water activities?(i.e. parasailing, snorkeling, scuba) Yes No If yes, please describe:Is there an association sponsored swim team? Yes No Are any of the above open to the public? Yes No Describe any other amenities/recreationHas the organization been involved in any merger or acquisition within the past twelve (12) months or are they contemplating any merger or acquisition in the next twelve (12) months? Yes No Provide details on any Mergers or Acquisitions within past 12 months or upload files below.Files on Mergers or Acquisitions Drop files here or Select files Max. file size: 50 MB. Does the organization currently have a tax exempt status under the U.S. Internal Revenue Code? Yes No Provide details on tax exempt status or upload files below.Files related to Tax Exempt Status Drop files here or Select files Max. file size: 50 MB. Have there been or is there now any pending dispute regarding the organization's tax exempt status? Yes No If yes, provide details on disputes regarding tax exempt status or upload files below.Files related to Tax Exempt Status Disputes Drop files here or Select files Max. file size: 50 MB. Does the organization have an incident response plan for data breaches that is tested at least annually? Yes No Details on not having incident response plan in place or upload files below.Files related to Incident Response Plan Drop files here or Select files Max. file size: 50 MB. If applicable, is the organization currently Payment Card Industry Data Security Standard (PCI/DSS) compliant? Yes No If no, provide details on PCI/DSS compliance or upload files below.Files related to PCI/DSS Drop files here or Select files Max. file size: 50 MB. Does the organization purchase First Party and Third Party Network Security and Privacy Insurance Coverage? Yes No If applicable, is the organization Health Insurance Portability & Accountability Act (HIPAA) / Health Information Technology for Economic & Clinical Health (HITECH) compliant? Yes No If no, provide details on HIPAA HITECH compliance or upload files below.Files related to HIPAA/HITECH Drop files here or Select files Max. file size: 50 MB. Does the organization receive more than 10% of their revenue from any governmental source? Yes No Does the organization offer, sell, advertise, market or solict any product or service, or debt collection, employing any automatic/robo dialing, mobile phone texting, faxing, or any other type of communications based mechanism or strategy governed under the rules and regulations of the Telephone Consumer Protection Act of 1991 (TCPA), The Fair Debt Collection Practices Act or any laws governing unsolicited advertising or contacts for collections or promotions of goods or services? Yes No Does the organization have a contract or agreement with any third party vendor to perform the above services on their behalf? Yes No Expiring D&O Insurance Information(if applicable)Expiring Insurance Company Policy Period LimitDeductiblePremiumD&O Desired Limits/Options(Up to $3,000,000 available. Financials required for limits exceeding $3,000,000) $1,000,000 aggregate limit of liability each policy year/$1,000,000 defense limit $2,000,000 aggregate limit of liability each policy year/$2,000,000 defense limit $3000,000 aggregate limit of liability each policy year/$3,000,000 defense limit Other If "Other", please specify: D&O Liability Loss/Claim HistoryIn the past three years has a claim been made, or is a claim now pending against the Entity or any person in his or her capacity as a director, officer, trustee, employee, volunteer or the Entity? Yes No If yes, provide details on any claims in past 3 years.Files related to any claims in past 3 years. Drop files here or Select files Max. file size: 50 MB. Are any of the persons or entities to be insured under the policy responsible for or has knowledge of any Wrongful Act, fact, circumstance, or situation which s(he) has reason to suppose might result in a future claim? Yes No If yes, provide details on knowledge or upload files below.Upload related files here. Drop files here or Select files Max. file size: 50 MB. It is agreed by all concerned that if any of the persons or entities to be insured under the policy are responsible for or has knowledge of any Wrongful Act, fact, circumstance, or situation not described above, any Claim subsequently emanating therefrom shall be excluded from coverage under the proposed insurance as to such persons or entities. Such responsibility of knowledge shall not be imputed to any other persons or entities to be insured under the policy for the purpose of determining the availability of coverage.Has any Directors' & Officers' Insurance, or other form of insurance similar to the proposed policy, on behalf of the Entity been declined, canceled or not renewed?(Question is not applicable in the state of Missouri) Yes No Is yes, provide details on insurance decline, cancellation, or non-renewal or upload files below.Files related to insurance decline, cancellation, or non-renewal. Drop files here or Select files Max. file size: 50 MB. Employment Practices LiabilityNumber of EmployeesFull timePart timeIndependent ContractorsVolunteersTotalList total number of employees in for following states:CAFLLAMATXTurnover percentage of employees within the past three (3) years?Year 1Year 2Year 3Does the organization anticipate making any reductions in the work force within the next twelve (12) months? Yes No If yes, please give details:Percentage of employees with salaries (including bonuses):Less than 50K50K-100K100K-250KMore than 250KDoes the Organization have an employee manual or handbook governing the terms and conditions of employment? Yes No If yes, please provide a copy: Drop files here or Select files Max. file size: 50 MB. Is it distributed to all employees? Yes No Does it require that employees sign and acknowledge its receipt? Yes No Does the Organization have written guidelines or procedures for addressing human resource personnel management in the following areas?Check all that apply. Hiring/Interviewing Employee at-will statement & employee contract disclaimer Discrimination Discipline Employee Evaluations Unlawful harassment or discrimination of third parties Termination procedures Disability accommodations Sexual harassment Workplace harassment New employee orientation Employee complaint/grievance procedures Does the Organization conduct employee and supervisor training in the areas mentioned above? Yes No NameThis field is for validation purposes and should be left unchanged.
