Union Liability Questionnaire 1Union Information2Claims History3Insurance Quote Information Let’s see what insurance coverage(s) your union should have!Name of Person Completing Form* First Last Email* Name of Union* Address of Union* Street Address Address Line 2 City State ZIP Website Address of Union Date from which the Union has Continuously Operated* MM slash DD slash YYYY FEIN Number for Union* LM File Number* Number of Directors & Officers* Number of Employees (excluding officers)* Total Revenue* Net Assets* Does the Union promote, sponsor and/or provide any form of insurance to its members (other than negotiated benefits), legal aid services or any other miscellaneous professional services?* Yes No Please provide details on services offered* Claims History1. Has the Union or any proposed Insured Person been involved in any civil or criminal action or litigation during the past five (5) years?* Yes No 2. In the past five (5) years, has the Union or any proposed Insured Person been involved in or have knowledge of any inquiry, investigation, complaint or notice from any State or Federal Regulatory Authority or Congressional or Legislative Committee regarding the activities, procedures or practices of the Union, its members, officers or employees?* Yes No 3. In the past five (5) years, has the Union or any proposed Insured Person reported any claims, or given wirtten notice of any facts, circumstances or situations which may reasonably be expected to result in a claim, under the provisions of any prior or current union liability policy or similar insurance?* Yes No 4. Is any proposed insured aware of any facts, circumstances or situations which may be reasonably be expected to result in a claim under the proposed policy?* Yes No Please provide additional details on any question above that you answered yes*NOTE: IT IS AGREED THAT WITH RESPECT TO QUESTIONS 1-4 ABOVE, IF SUCH FACT, CIRCUMSTANCE OR SITUATION EXISTS, WHETHER OR NOT DISCLOSED, ANY CLAIM ARISING THEREFROM IS EXCLUDED FROM THIS PROPOSED COVERAGE. Insurance Quote InformationBuilding and Property InsuranceMailing Address (if different than physical address) Street Address Address Line 2 City State ZIP Policy Effective Date (not required) MM slash DD slash YYYY Do you own or lease your Union office space? Owned Leased Building Replacement Value (if building owned) Union Property Replacement Value (these are the contents inside your office space owned by the Union) Computer Equipment Replacement Value Total Building Square Footage Square Feet of your Office Do you sublease any portion of your building? Yes No Please provide details on your subleaseValue of Improvements & Betterments (if you are required by lease to insure) Building Age Utility/Roof Updates (year roof/utility was last updated) Building Construction Material (brick, masonry, etc.) Number of Stories of your Office Building Sprinkler System Yes No Burglar Alarm Yes No Has there been any losses (claims) in the past 5 years? Yes No Workers Compensation Insurance8755: Labor Union All Officers Estimated Annual Payroll 8810: Clerical Office Employees Estimated Annual Payroll Business Automobile InsuranceDoes your Union own Vehicles? Yes No Please Provide Year, Make, Model, and VIN for all VehiclesPlease Provide Name, DOB, Driver's License Number, and Garaging Zip Code (where car is parked overnight) for all DriversPlease upload any current insurance policies the union has in-forceMax. file size: 64 MB.