DUI or DWI Leaving the scene of an accident Hit and run G. & HIRED AUTO INFORMATION: How many volunteers or employees drive their personal vehicle for business use? H. PUBLIC ENTITY ERRORS & OMISSIONS (For Public Entities Only): Do you have any existing coverage written on a claims-made basis? If yes what is your Retroactive Date? I. DIRECTORS AND OFFICERS (For Nonprofits Only): Date of Incorporation/Formation. Do you have any existing coverage written on a claims-made basis? If yes what is your Retroactive Date? Has the insured been involved in any of the following in the past: Investigations or Inquiries by any Federal, State or local YES NO authorities? Civil or criminal actions or administrative proceedings YES NO charging violations of any Federal or State law or regulation or any other criminal action? Anti-trust litigation? YES NO J. EMPLOYMENT PRACTICES: Do you have any existing coverage written on a claims-made basis? If yes what is your Retroactive Date? Do you have a director of personnel or other similar position: YES NO Do you have established written guidelines and/or procedures for employment practices YES NO
DUI or DWI Leaving the scene of an accident Hit and run G. & HIRED AUTO INFORMATION: How many volunteers or employees drive their personal vehicle for business use? H. PUBLIC ENTITY ERRORS & OMISSIONS (For Public Entities Only): Do you have any existing coverage written on a claims-made basis? If yes what is your Retroactive Date? I. DIRECTORS AND OFFICERS (For Nonprofits Only): Date of Incorporation/Formation. Do you have any existing coverage written on a claims-made basis? If yes what is your Retroactive Date? Has the insured been involved in any of the following in the past: Investigations or Inquiries by any Federal, State or local authorities? YES NO Civil or criminal actions or administrative proceedings charging violations of any Federal or State law or regulation or any other criminal action? YES NO Anti-trust litigation? YES NO J. EMPLOYMENT PRACTICES: Do you have any existing coverage written on a claims-made basis? If yes what is your Retroactive Date? Do you have a director of personnel or other similar position: YES NO Do you have established written guidelines and/or procedures for employment practices YES NO
17_18_SLIP_New_Business_Application.docx