NPCC eSubmission

Northeast Agencies Inc.
Lisa Williams, Sr. Account Executive
877.319.6568 ext. 2977
Lisa.Williams@crystalnea.com

CLIENT INFORMATION


Your Email address :
Your Contact Name :

Are you requesting Property coverage?:
Are you requesting Professional Liability?:
Are you requesting Abuse Liability?:
Are you requesting Automobile?:
Have you had any claims in the past 5 years?:
Are you interested in Directors & Officers coverage through Frank Crystal & Co.?:
Desired effective date of coverage?:

Applicant information
Named Insured:
Location Address:
City:
State:
Zip:
Billing information
Check if Billing address the same as contact address?
Billing Address:
Billing City:
Billing State:
Billing Zip:
Phone :	999-999-9999
Ext:
Federal Identification Number:	99-9999999
Number of Years In operation:	(not years experience)
Number of Years Under Present Management:
Website Address:
Description of Operation:

GENERAL LIABILITY
Coverage for an insured when negligent acts and/or omissions result in bodily insurance and property damage arising on the premises when someone is injured in the general operation of the business.
If You have students, how many per year, 0 for no students:
Do you have an additional location to insure?:
Annual Revenue:
What special events do you run or hold annually if any (dances, runs, walks, conference, golf outings, other fundraisers, etc.?:

# Events	Event Type	# Attendees	# Days	Revenue

General Liability Limit: Help
Total sq feet occupied by this insured: Help
Most recent carrier name:	(enter None if no prior carrier)
Do you need to have an additional insured added to your policy? If yes, please provide name, address and reason:
Describe your nonprofit organization:

PROPERTY INFORMATION
Covers the property, also known as building and contents coverage. Contents includes such items as the furniture, fixtures, equipment, machinery, merchandise, materials, and all other personal property owned by the insured and used in the insured's business.
Do you own or lease office space?:
Business Personal Property Limit: Help
Construction of Building :
Building Year Built:	(YYYY)
If building over 20 years old, year updates done:	Wiring:
	Plumbing:
	Heating:
	Roof:
Central Station Alarm:
Smoke Detectors - Hard Wired?:
Emergency Lighting?:
Are evacuation routes posted throughout the building?:
Are exit signs illuminated?:
Are there at least two exit doors per building?:
Are exit doors equipped with panic hardware?:
Is smoking permitted inside the premises?:
Is the building sprinklered?

PROFESSIONAL INFORMATION
# of Full Time employees:
# of Part Time employees:
# of Volunteers:
Does your current insurance program provide Professional Liability coverage?:
If yes, indicate the limit of liability:
Is Professional Liability :
Retroactive Date:

Position	# Full Time	# Part Time
Psychologists, Therapists or Nurses
Social Workers
Counselors, Aides
Teachers/Instructors/Activity Staff, etc.

Do you use independent contactors for any of the above?:
Are there written agreements with them?:
Are certificates of malpractice/liability insurance obtained and maintained for all contracted service providers (independent contractors)?:
Please indicate the limits of liability:

ABUSE INFORMATION
Do you perform background checks on your staff?:
Does your employment or volunteer application include questions about felony convictions?:
Do you have written procedures or formal training for staff on what is acceptable behavior with clients, students, etc.?:
Have you had any abuse incidents or claims in the past?:
If Yes, explain:

AUTOMOBILE INFORMATION
What percentage of employees use their own vehicles regularly (daily/weekly) for agency business?
Describe use:
Do you require employees to carry and show evidence of personal insurance?
What limits are required?:
Do you run MVRs on employees?:
Do you have a driver safety training program?:
Does your Agency transport clients?:
Do you own/lease any vehicles- If so list below:

CLAIM HISTORY

Date of Claim	Type of Claim	Amount	Details of Claim

OTHER COVERAGES - ADDITIONAL INFORMATION
Other Coverages Requested / Additional Information / Instructions:

RESIDENTS OF NEW YORK APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND SHALL ALSO BE SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION.

v.2012.07