oswald companies - GPE Form

Who will be covered:

Use or enter the defines groups as needed - indicate the number of participants in the "Participants" column and enter any
considerations or notes in the space provided

Defined Group

Participants

Notes / Comments

Directors / Officers

Parters

Organization Name and Address:

Name:
Address:
City:		State:		Zip:
Phone Number:	() -Second partThird part		Fax Number:	() -Second partThird part

Group Excess Contact:

Name:
Phone Number:	() -Second partThird part	Fax Number:	() -Second partThird part
Email:

Optional Coverages:
Check all that apply for optiional quotes

	Employment Practice Liability Insurance (EPLI)
	E&O Group Excess Coverage for Organization ($1 million included; up to $2 million available)
	Charitable Board (coverages varies by state)
	Higher Supplemental Defense Coverage ($10,000 included; up to $100,000 available)

Excess Liability limits requested:
Indicate all applicable

Geographic Breakdown:
List all states where members of the defined groups reside

NOTE: For groups of 25 or less, a Group Personal Excess Participant Questionnaire needs to be completed by each participant prior to obtaining a quote:

	Yes, please email me the participant questionnaire

Description of Business:

Group Personal Excess Liability Application