D & O "Quick Quote" Form
Complete the form below and we'll send you a "quick quote" on a new Directors & Officers Liability policy. Questions? Email Peter Andrew, CEO, Council Services Plus, at
or call (800) 515-5012 x 125.
Is your non-profit a current paid NYCON member?
Organization Street Address
Street Address Line 2
Primary Contact First Name
Primary Contact Last Name
Primary Contact Title
Primary Contact Email
Do you currently have D & O insurance?
Policy's expiration date:
Date of your nonprofit's incorporation:
Date of your nonprofit's IRS determination:
Brief description of your organization's services:
Do any affiliates or subsidiaries need to be covered under this policy?
Current number of employees:
Number of employees terminated last year:
Number of volunteers (including board members):
Using the records from your last fiscal year:
Does your nonprofit do credentialing, accreditation, licensing, peer review or standard setting?
Please indicate if this subsidiary is:
In the last five years have there been any civil, criminal or administrative proceeding brought against the organization, its subsidiaries, board, staff or volunteers?
In the last five years have there been any mergers, acquisitions or similar reorganizations OR are you expecting such in within the next year?
Are you aware of any fact, circumstance, or situation that may result in a future claim?
Would you like a quote for a Fiduciary Liability policy?
Coverage limit requested:
Retirement Plan Information
What type of retirement plan does your nonprofit offer?
Employee Stock Ownership (ESOP)
Current Plan Assets:
Number of Plan Participants:
Are you currently working with a representative at Council Services Plus (NYCON's insurance affiliate)?
Name of the Council Services Plus representative you have been working with:
I understand that pending or prior claims or known circumstances that result in a claim will not be covered under a new D & O policy. After you complete and submit this form you will receive a non-binding “indication” of eligibility, terms and cost. Prior to binding coverage we will require (a) proof of NYCON membership and (b) insurance company application signed by President or Executive Director.