Directors and Officers Insurance Quote Request Name of Parent Organization/Club Name*What year was applicant's business established?*What is the state of Incorporation?*Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PhoneEmail* WebsiteAnnual 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 DateDo you currently have Directors & Officers Liability InsuranceYesNoIf yes, how long has it been continuously in force?Current PremiumTotal number of full and part time employeesTotal number of volunteersHow 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?*YesNoHow 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 DetailsPlease list any additional comments