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Name of Organization
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What is the name of the nonprofit or social service organization?
Primary Contact
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Last
Who should be the primary contact in your organization if we need additional information?
Phone Number for Primary Contact
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Email for Primary Contact
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Name of Executive Director
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Last
If you do not have an Executive Director, who is the Board Chair/President?
Primary Address
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City
State
Zip Code
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What is the primary address at which your organization operates?
Website or Social Media Page
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Is this a Non Profit Organization with a tax exempt status as defined by the Internal Revenue Service?
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Working on it
What is the organization's Federal Tax ID Number (FEIN)?
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Number of Years in Operation
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Please provide a detailed description of the operations
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Does the organization of any current insurance in place? If so, what kind of policies? (click all that apply)
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General Liability
Professional Liability
Directors & Officers / EPLI
Property
Automobile
No Current Insurance
What kind of insurance is the organization interested in?
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General Liability
Professional Liability / E&O
Directors & Officers / EPLI
Workers Compensation
Property
Crime / Employee Dishonesty
Automobile
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