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  1. Insurance Quote Continued

Insurance Quote Form (Continued)

  1. Insurance Quote Continued

Insurance Quote Form (Continued)

Providing specialized insurance programs for Non Profits, Churches, Camps, and Ministries.

Insurance Quote ContinuedAnton Thornquist2023-03-21T17:35:14-04:00

"*" indicates required fields

Thanks for submitting the initial discovery information for your organization.

If you would like to continue with your application so we can start quoting right away, please click Continue below to keep going. The remaining questions should only take about 5-10 minutes to complete.

Insurance Types

Directors and Officers Information

List of direct or indirect subsidiaries or other entity Applicant controls
Click the (+) icon to the right to add more Subsidiaries.
Example: ABC Foundation Inc, 100%, 01/01/2020, Non-Profit
Entity Name
Controls %
Date Acquired
For Profit / Non-Profit
 
Any anti-trust, copyright, or patent litigation in the past 5 years?*
Any disciplinary action by any regulatory agency or association in the past 5 years?*
Any action where a license was revoked or suspended in the past 5 years?*
Any administrative proceeding charging violation of a federal or state law or regulation in the past 5 years?*
Any other criminal actions in the past 5 years?*
Does Applicant anticipate being involved with any mergers, acquisitions, or consolidations in the last 24 months or next 12 months?*
Does Applicant anticipate changes in board of directors or senior management in the last 24 months or next 12 months?*
(other than death or retirement)

Employment Practices

Employee counts below should be U.S. based employees/volunteers.
Does Applicant have an employment handbook?*
Does Applicant use an employment application for every potential employee?*
Does Applicant have an "At Will" provision in the employment application or handbook?*
Has the Applicant implemented an anti-sexual harassment policy?*
Has the Applicant implemented any anti-discrimination policy?*
Does the Applicant use outside employment counsel for employment advise?*

Fiduciary Liability

List plans for Fiduciary coverage
Click the (+) icon to the right to add more Plans.
Plan Name
Established Year
Contributions
Type*
Participants
Administrator**
 
* Enter the number for the Type of plan
1 - Employee Welfare Benefit Plan (as defined by ERISA)
2 - Defined Contribution Plan (as defined by ERISA)
3 - Defined Benefit Plan (as described by ERISA)
4 - Other
Does any plan(s) employ the investment, trustee, actuarial, legal, administrative, custodial, or benefits consulting services of any outside provider?*
Has termination been requested or contemplated for any plan?*
Has any amendment to any plan been made or contemplated within the past 2 years, or is any amendment now contemplated, which has or might result in any reduction of benefits or potential portion of cost?*
Has any plan been spun-off (sold), transferred, or terminated?*
Are there or have there been within the last 3 years any known or alleged violations of ERISA or any similar statutory or common law of the U.S.A., Canada, or any other jurisdiction to which a plan is subject?*
Does the Applicant have any information to suggest or indicate that the plans it sponsors may be under government or regulatory investigation with regard to plan's funding, administration, or investment strategies?*
Is Form 5500 filed on an annual basis for each plan?*

Workplace Violence

Please enter a number greater than or equal to 0.
Please enter a number greater than or equal to 0.
Does Applicant have an employee assistance program?*
Does Applicant have a progressive disciplinary policy?*
Does Applicant have an employee complaint/grievance resolution procedure?*
Does Applicant have a written policy on workplace violence that is circulated to all employees?*
Does Applicant train employees to recognize, report, and respond to potentially hostile situations?*
Does Applicant have a process for performing background checks for all potential employees?*
In the past 12 months, has Applicant been involved with any layoffs, staff reductions, or facility closings?*
In the next 12 months, is Applicant contemplating any layoffs, staff reductions, or facility closings?*
Has Applicant or any other person proposed for coverage herein been subject of, or involved in any incidents of workplace violence in the past 5 years?*

Internet Liability

Add Website 2
Add Website 3
Does the Applicant conduct transactions (e-commerce) on the website?*

Current Insurance Coverage

Does Applicant currently have any insurance policies?
(Check all that apply, or choose None)
With respect to the above coverage, has any Underwriter refused, canceled, or non-renewed coverage?*

Summary

Has Applicant given written notice under the provisions of any prior policies providing similar insurance or claims, or of specific facts or circumstances which might give rise to a claim being made against any person or entity applying for this insurance?*
No person applying for this coverage is aware of any facts or circumstances that may give rise to a claim that would fall within the scope of any proposed coverages for which Applicant has applied*
Drop files here or
Max. file size: 12 MB.
    Consent*

    The Undersigned states that he/she is an authorized representative of the Applicant and declares to the best of his/her knowledge and belief and after reasonable inquiry, that the statements set forth in the Application (and any attachments submitted with this Application) are true and complete and my be relied upon by Company in quoting and issuing the policy. If any of the information in this Application changes prior to the effective date of the policy, the Applicant will notify the Company of such changes and the Company may modify or withdraw the quote or binder.

    The signing of this Application does not bind the Company to offer, or the Applicant to purchase the policy.

    Clear Signature
    This field is for validation purposes and should be left unchanged.
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    CTG Insurance

    10751 S Saginaw St Suite A
    Grand Blanc, Michigan 48439
    Phone: 800-732-0096
    Secondary phone: 810-695-0096

    CTG Insurance
    P.O. Box 8
    Grand Blanc, MI 48480

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