Directors and Officers Insurance Quote Request Are you an insurance agent or broker?* Yes No Name of Parent Organization/Club Name* What year was applicant's business established?* What is the state of Incorporation?* Address* Street Address 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 PhoneEmail* Website Annual Gross Revenue*$0 - $50,000 (up to 15 employees)$50,001 - $100,000 (up to 15 employees)$100,001 - $150,000 (up to 25 employees)$150,001 - $200,000 (up to 25 employees)Limit of Liability*$1,000,000 limit per claim / aggregate$500,000 limit per claim / aggregate$250,000 limit per claim / aggregateDesired Effective Date Do you currently have Directors & Officers Liability Insurance Yes No If yes, how long has it been continuously in force? Current Premium Total number of full and part time employees Total number of volunteers How many club members do you currently have? Does your club/group have:Check those that apply By Laws Articles of Incorporation None of the above Is the applicant recognized by the state as a non-profit or does it have tax exempt status under the US Internal Revenue Code?* Yes No How did you hear about us*Internet Search (Please specify words searched below)American Kennel ClubFriend/ReferralLinkedInTrade Show (Please specify below)United Kennel ClubOther Club or Organization (Please specify below)Other/Please Specify Details Please list any additional comments Δ