Organization *

Physical Address *

Mailing Address (if dfferent from physical addresss)

County *

What county are you located in?

First Name *

Last Name *

Title *

Website or Social Media Page

Email *

Phone *

Fax

Preferred method of contact

Please select one:

email

phone

Membership with Kentucky Nonprofit Network

Are you currently a Kentucky Nonprofit Network member?

Yes

No

What type of quote for services do you seek?

Directors & Officers Insurance

General Liability Insurance

Property Insurance

Other

Mission/Description of your organization's operations

Total annual revenues (please indicate expected revenues for new organizations)

Total number of employee/service providers

Full-time Employees

How many full-time eligible employees (working 30 or more hours/week) work for your organization?

Part-time employees

How many part-time employees (work less than 30 hours per week) for your organization?

Total number of volunteers

Any claims/losses in the past 5 years?

Yes

No

If yes, please elaborate.

Square Footage

Construction type

frame

joisted masonry

noncombustible

masonry noncombustible

modified fire resistive

fire resistive

Year Built

Building Limit | Building Insured Value

Business Limit | Personal Property Insured Value

Additional Quotes

Do you have additional properties you would like quoted? If so, please let us know additional details. Details to include might be:

1. Construction type of building (frame, noncombustible, modified fire resistive, joisted masonry, masonry noncombustible, fire resistive).
2. Year built.
3. Building Limit | Building Insured Value ($)
4. Business Limit | Personal Property Insured Value ($)

Additional Services

Would you like some quotes for additional coverage?

Such as:

• Auto Insurance
• Workers Compensation
• Other

Please let us know what you need. Or share any additional comments here.