♛ WANG INSURANCE EST. 1979

2620 Judah St, San Francisco CA 94122
415.731.7062 · info@wangins.com
www.wangins.com · LIC. 0743903

Nonprofit Client Intake Form

Package / Nonprofit BOP · Directors & Officers · Employment Practices Liability

Organization information

Legal name of organization *

DBA / trade name (if any)

Federal EIN *

IRS 501(c) classification *

Year founded *

Website

Primary mailing address *

Primary contact name & title *

Contact phone *

Contact email *

Mission & operations

Mission / purpose *

Geographic area served *

Services / programs offered

Does the org serve minors? *

Yes No

Medical / counseling services provided?

Yes No

Food service / kitchen operations?

Yes No

Vehicle / transportation operations?

Yes No

Premises

All premises / locations to be insured *

Building ownership *

Approx. total square footage

Building construction type (if owned)

Year building was built (if owned)

Sprinkler system on premises?

Yes — full Partial No

Central station burglar alarm?

Yes No

Central station fire alarm?

Yes No

Important: Premium discounts may apply for sprinkler systems and central station alarms. If these protections are ever removed or become non-operational, please notify Wang Insurance immediately, as coverage and pricing may be affected.

Property values — business personal property (BPP)

Building replacement cost value (if owned)

BPP / contents replacement cost value *

Business income / extra expense limit desired

Business income indemnity period desired

Special equipment or items needing scheduled coverage

General liability

GL limit desired *

Prior GL carrier & policy number

GL expiration / renewal date *

Current GL annual premium (if renewing)

Additional insured requirements

Special events, fundraisers, or off-premises activities in the policy period?

Any GL claims or losses in the past 5 years? *

Workers' compensation & staffing

Number of full-time employees *

Number of part-time employees

Number of regular volunteers

Total annual payroll (all employees) *

Independent contractors (1099) used? *

Yes No

Current WC carrier & X-Mod (if applicable)

Coverages needed (check all that apply)

General Liability Business Personal Property (BPP) Building coverage (if owned) Business Income / Extra Expense Hired & Non-Owned Auto Inland Marine / Equipment Floater Cyber Liability / Data Breach Commercial Umbrella / Excess Liability Workers' Compensation (CA) Crime / Employee Dishonesty / Fidelity Bond Liquor Liability (if alcohol served at events) Sexual Abuse & Molestation (SAM) Coverage Professional Liability / E&O

Acknowledgment: By submitting this form, the applicant certifies that the information provided is accurate and complete to the best of their knowledge. The applicant agrees to notify Wang Insurance promptly of any material changes in ownership, operations, premises, exposures, or staffing throughout the policy term. Providing incomplete or inaccurate information may affect coverage. This form does not bind coverage; a quote is subject to underwriter review and acceptance. Wang Insurance, LIC. 0743903.

Thank you — your Package / BOP intake has been submitted to Wang Insurance. We will be in touch shortly.

Something went wrong. Please try again or email us directly at info@wangins.com.

Organization information

Legal name of organization *

Federal EIN *

IRS 501(c) classification *

Year founded *

Annual revenue (most recent fiscal year) *

Total assets *

Primary contact name, title & email *

State of incorporation *

States where the org operates

Board of directors

Number of board members *

Number of independent (outside) directors

Board audit committee in place?

Yes No

Financials independently audited annually?

Yes — audited Reviewed only No

Directors or officers who are also employees (dual-hat roles)?

Planned or recent changes to board composition or leadership?

D&O — directors & officers liability

D&O limit desired *

Retention / deductible desired

Current D&O carrier & policy number

D&O expiration / renewal date *

Retroactive date on current policy

Current D&O annual premium

Coverage sides desired

Side A — Individual director / officer protection Side B — Corporate indemnification reimbursement Side C — Entity coverage

Government, foundation, or major donor grants / restricted fund obligations?

Any D&O claims, demands, or circumstances in the past 5 years? *

Any pending / threatened litigation, investigations, or regulatory inquiries? *

Mergers, acquisitions, restructuring, or program discontinuations in past 3 years?

EPLI — employment practices liability

EPLI limit desired *

EPLI retention / deductible desired

Number of full-time employees *

Number of part-time employees

Total annual payroll *

Employees hired in past 12 months

Employees terminated in past 12 months

Written HR / anti-harassment policy in place? *

Yes No In development

Annual EPLI / HR training conducted?

Yes No

Written employment agreements used?

All employees Some No

Independent contractors (1099) used? *

Yes No

Any EPLI claims, EEOC charges, DFEH/CRD complaints, or wage & hour disputes in past 5 years? *

Third-party EPLI needed (claims by clients, donors, or vendors)?

Yes No Unsure — advise me

Crime & fiduciary liability (optional add-ons)

Crime / employee dishonesty / fidelity bond desired?

Yes No Unsure

Crime limit desired (if yes)

Does the org manage a pension / retirement plan?

Yes No

Fiduciary liability desired (for plan sponsors)?

Yes No Unsure

Any employee dishonesty, fraud, or theft incidents in past 5 years?

Additional notes

Reason for marketing coverage

Any prior D&O or EPLI carrier non-renewal or cancellation? *

Yes No

Anything else we should know about the organization or its risk profile?

Acknowledgment: By submitting this form, the applicant certifies that the information provided is accurate and complete to the best of their knowledge. The applicant agrees to notify Wang Insurance promptly of any material changes in ownership, operations, premises, exposures, staffing, or board composition throughout the policy term. Providing incomplete or inaccurate information may affect coverage. This form does not bind coverage; a quote is subject to underwriter review and acceptance. Wang Insurance, LIC. 0743903.

Thank you — your D&O / EPLI intake has been submitted to Wang Insurance. We will be in touch shortly.

Something went wrong. Please try again or email us directly at info@wangins.com.

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