Volunteer / Employee Dishonesty Coverage

INSURANCE AGENCY
(Please show full name of agency):

ADDRESS:

CITY:

STATE:

ZIP CODE: -

PHONE: - -

FAX: - -

AGENCY CONTACT :

EMAIL ADDRESS:

IF YOU ALREADY ARE AN ACTIVE AGENCY WITH CIMA, PLEASE PROVIDE YOUR AGENCY CODE HERE (YOUR ACCOUNTING DEPARTMENT MAY HAVE THE CODE, OR CALL OUR VOLUNTEERS INSURANCE SERVICE STAFF AT 800.222.8920 TO OBTAIN THE CODE.) YOU WILL ALSO NEED TO PROVIDE YOUR AGENT NAME FURTHER DOWN THE SCREEN.

IF YOU ARE NOT ALREADY AN ACTIVE AGENCY WITH CIMA, PLEASE COMPLETE THE FOLLOWING INFORMATION.
(EITHER THE AGENCY CODE OR THE FOLLOWING INFORMATION IS REQUIRED, IN ORDER TO COMPLETE THIS APPLICATION):

PLEASE CHECK ONE:

INDIVIDUAL/SOLE PROPRIETOR PARTNERSHIP

CORPORATION OTHER

TAX ID NUMBER (IF COMMISSIONS ARE PAID TO CORPORATION OR PARTNERSHIP):

Your Professional Liability Insurer:

Your Professional Liability Policy Number:

POLICY EXPIRATION DATE: formatted [mm/dd/yy]

PRODUCER'S LICENSE NUMBER FOR STATE IN WHICH INSURANCE IS BEING REQUESTED:

LICENSE EXPIRATION DATE: formatted [mm/dd/yy]

SPONSORING NONPROFIT ORGANIZATION USING THE VOLUNTEERS:

MAILING ADDRESS:

CITY:

STATE:

ZIP CODE: -

PHONE: - -

FAX: - -

CONTACT PERSON AT SPONSORING NONPROFIT ORGANIZATION:

TITLE:

EMAIL ADDRESS:

Do you perform any overseas business activities? Yes No

If yes, do your overseas business activities breach any U.S.A. Sanctions/Regulations? Yes No

Volunteer / Employee Dishonesty Coverage

For Insurance Brokers Accessing the Volunteers Insurance Service (VIS®)

Volunteer / Employee Dishonesty Coverage

PREMIUM COMPUTATION IS AS FOLLOWS: