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How did you hear about the Brokers' Risk Trustees' E&O Coverage?
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1)
Name of Association
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2)
Address of the Trust
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City
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State
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Zip
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email
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Phone
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Fax
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3)
Name of Executive Director
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4)
Date Association established
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5)
Association's Gross Income (past 12 months)
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6)
Fiscal Year
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7)
Number of Salaried Officers and/or Directors
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8)
Number of Non-Salaried Officers and/or Directors
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9)
Number of Technical Staff
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Total number of Employees
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10)
Are you a Not-For-Profit Organization?
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11)
Does the Association have an interest in any “For Profit” entities?
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If Yes, please provide full particulars (Name, Description of Service, and Gross Income)
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12)
Is the Association State, Regional, National or International in scope?
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Number of Members
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13)
Does the Association act as an Insurance Broker, Insurance Agent or Insurance Consultant?
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If yes, is the association and all employees properly licensed?
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If yes, does the Association or its employees carry Insurance Agents & Brokers E&O Coverage?
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14)
Is the Association directly involved in the promotion of any specific product or services to Association Members or other entities which will produce a royalty or fee for the Association?
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Is the Association involved with sponsorship of any specific product or services?
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If yes to either in question 14, please describe
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15)
Does the Association publish any magazines, periodicals or bulletins?
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Attach Publication
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Attach Publication
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Attach Publication
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16)
Does the Association publish a technical manual?
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If yes, please describe the nature of this manual
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17)
How many State Conventions will you organize each year?
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How many National Conventions?
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18)
During the last 5 years, has any claim been made, or is any claim now pending, against the Association, its Directors, Officers, or Employees?
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If yes, please provide the following
 
Date of Claim
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Amount Paid
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Type of Claim
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19)
Is the Association aware of any circumstances or any allegations or contentions which may result in a claim being made against the Association or any of its past or present Directors, Officers, Trustees or Employees?
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If yes, please provide full details
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20)
Does the Executive Director, Secretary, or acting Manager of the Association work for the Association?
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21)
Does the Association do any of the following? (Check all that apply.)

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If yes to any in #21, please provide full details.
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22)
Does the Association maintain primary personal injury coverage?
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If yes, what limit?
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23)
Are the following coverages afforded? (Check all that apply.)              

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Please attach copies of following documents:
Latest Audited Financial Report for the Association (Indicating Income/Expenses and Assets/Liabilities) to include subsidiary
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Copies of endorsement, royalty and administrative services contracts
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Trust Document and Bylaws
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List of Current Directors, Officers and Trustees
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Warranty

The Undersigned declare that to the best of their knowledge the statements set forth herein and any documents and information submitted in connection herewith are true, accurate and complete and that every effort has been made to obtain sufficient information from each and every person proposed for this coverage to facilitate the proper and accurate completion of this Application Form. The undersigned further declare that they have not suppressed, omitted, or misstated any material facts. The undersigned agree that if the information supplied on or in connection with this Application Form changes between the date of this Application Form and the effective date of the coverage, the undersigned will immediately notify Brokers’ Risk Placement Service, Inc. and Brokers’ Risk Placement Service, Inc., in its sole discretion, may withdraw or modify any outstanding quotations or authorization or agreement to bind coverage. The signing of this Application Form does not bind the applicant to purchase the coverage. However, it is agreed that this Application Form and any documents or information submitted herewith shall be the basis of the contract should a Coverage Agreement be issue and are to be considered as incorporated in and constituting part of the Coverage Agreement.

Required

 

This application must be signed and dated by an Officer of the Association, and not earlier than 60 days before the proposed effective date.

 
Digital Signature
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By typing your name in this box and clicking submit you are accepting the terms of this Application Form. (Must be signed by an Officer of the Association)
 
Title
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Applicant's Email
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All data on this application is considered highly confidential and is only for Company's use. Signing this Application Form does not bind the Company to provide this Insurance, but it is agreed that this Application Form shall be made a part of this certificate and shall be the basis of the contract should the certificate be issued.
Security Code
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