Name: Anchorline Insurance
Price range: $$

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General Organization Information

Basic information about your organization.

Legal Name of Organization*

DBA / Operating Name (if different)

EIN (Employer Identification Number)*

Date Organization Was Established

Nonprofit Status*

501(c)(3) Nonprofit

Other Nonprofit Designation

Not Currently a Nonprofit

Main Phone Number*

Website URL

Include https://

Mailing Address & Physical Location(s)

Mailing Address*

Street Address Address Line 2 City State ZIP Code

Total Number of Locations*

Physical Location Address(es)*

If different from the mailing address, or if there are multiple locations, please list each address (one per line).

Primary Contact Information

Basic information about the primary contact for this operation.

Primary Contact Name*

First Name Last Name

Primary Contact Title

Primary Contact Email*

Primary Contact Phone*

Staffing & Personnel

Total Paid Employees (Full-Time)*

Total Paid Employees (Part-Time)

Total Annual Payroll

Approximate total annual payroll for all employees (e.g., $180,000).

Job Descriptions / Duties for Staff Categories

Briefly describe the duties for each staff category, especially anyone in a clinical or counseling role.

Are background checks conducted on employees?*

Yes - at hiring only

Yes - periodically

No

Does the organization have an employee handbook with HR policies (harassment, termination, etc.)?*

Yes

No

Do any employees interact one-on-one with minors?*

Yes

No

Property & Equipment

Are your location(s) owned or leased?*

Owned

Leased

Both (some owned, some leased)

Lease Terms and Any Landlord Insurance Requirements

Square Footage of Each Location*

Construction Type and Year Built for Each Location*

Replacement Value of Owned Building(s)

Replacement Value of Contents / Equipment*

What security systems are in place?

(Select all that apply)

Alarm System

Security Cameras

Monitored Security Service

None

Has the organization had any prior property losses (fire, water damage, theft) in the last 5 years?*

Yes

No

Please describe the loss(es), including approximate dates

Governance & Board

Number of Board Members*

How often does the board meet?*

Are board members compensated?*

Yes

No

Does the board carry out oversight of finances, HR policies, and risk management?*

Yes

No

Has the organization had any past D&O claims or lawsuits against board members or officers?*

Yes

No

Please provide details, including approximate dates and current status

Does the organization have written bylaws and a conflict-of-interest policy?*

Yes

No

Cyber & Data Security

What systems store client medical/personal information?*

(Select all that apply)

Electronic Health Record (EHR) System

Paper Records

CRM / Database

Cloud Storage

Other

Is data encrypted at rest and in transit?*

Are staff and volunteers trained on data privacy and phishing awareness?*

Yes

No

Has the organization experienced any data breach, ransomware event, or unauthorized access in the past 5 years?*

Yes

No

Please describe, including approximate date and how it was resolved

Who Has Administrative Access to Client Databases?*

List roles/titles (not necessarily names) with administrative access.

Financial & Prior Insurance Information

Does the operation currently have any insurance policies?*

Yes

No

List Current Insurance Carrier(s)

Policy Type

Carrier Name

Expiration Date (mm/dd/yyyy)

Policy Limit

Has any coverage been declined, cancelled, or non-renewed in the past?*

Yes

No

Please describe

Does the organization have any current or prior claims/lawsuits (any line of coverage) in the last 5 years?*

Yes

No

Please provide the date, description, and status for each claim

Does the organization host fundraising events involving the public (galas, walks, etc.)?*

Yes

No

Please describe the event(s)

Additional Information

This information will be used to begin a no-cost, no-pressure coverage review tailored to your organization.

Is there anything else about your organization's operations that your insurance advisor should know?

Additional Documents (Optional)

e.g. Current insurance policies, schedule of drivers or vehicles, certificates of insurance, landlord contracts, licenses, etc.

Drop files here or

Max. file size: 20 MB.

All the above information is accurate and true to the best of my knowledge.*

Yes

Insurance Application for Medical, Dental, & Private Practice Clinics

General Organization Information

Mailing Address & Physical Location(s)

Primary Contact Information

Operations & Services Offered

Medical & Clinical Operations

Staffing & Personnel

Volunteers

Abuse & Molestation Risk Management

Property & Equipment

Vehicles & Mobile Medical Units

Governance & Board

Cyber & Data Security

Financial & Prior Insurance Information

Additional Information

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Insurance Application for Medical, Dental, & Private Practice Clinics

General Organization Information

Mailing Address & Physical Location(s)

Primary Contact Information

Operations & Services Offered

Medical & Clinical Operations

Staffing & Personnel

Volunteers

Abuse & Molestation Risk Management

Property & Equipment

Vehicles & Mobile Medical Units

Governance & Board

Cyber & Data Security

Financial & Prior Insurance Information

Additional Information

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Don’t have an account?

Necessary Cookies

Functional Cookies

Statistics Cookies