NP Unemployment Compensation

	COMPLETE EQUITY MARKETS, INC.
RENEWAL APPLICATION	In California dba Complete Equity Markets Insurance Agency, Inc.
UNEMPLOYMENT COMPENSATION INSURANCE	1190 FLEX COURT
NON PROFIT CORPORATION	LAKE ZURICH, ILLINOIS 60047
	(847) 541-0900 ● (800) 323-6234
	bslawin@cemins.com ● Fax (847) 541-0444

YOUR OFFICE MUST HAVE 501(c)(3) TAX STATUS TO BE ELIGIBLE FOR THIS INSURANCE PROGRAM
This is an application for renewal quotation for unemployment compensation liability insurance. All information disclosed on this application together with any supplementary information regarding the applicant is considered to be privileged and will be held in strict confidence with the exception that it must be made available to the underwriting insurance entity. It will not be released unless your written consent is given.

Proposed Period of Coverage +

to +

Name of Organization *

Address

City

State *

Zip Code

Mailing Address

Telephone Number

Reimbursing ID Number

Executive Director or Finance Director

Administrator

Please complete the following questions.

1. Please indicate current funding sources and revenues

Legal Services Corporation (LSC)

Other Federal Agency

(specify)

State

County

Local or Private Grants

Contributions

Ticket Sales

Other Revenue

2. Is your budget fully funded for the proposed period of coverage?

Yes

No

If no, indicate reason for deficit and how you plan to obtain full funding

3. If you cannot obtain full funding, what do you plan to do with your employees? (Please provide full explanation on a separate sheet of paper)

4. Are there any changes in regulations or policies that you are aware of that could result in funding cutbacks and/or lay offs?

Yes

No

If yes, explain a) Funding source involved

b) Nature of change

c) Expected number of lay offs

d) Expected budget dollars lost

5. Are you aware of any circumstances that are likely to give rise to a substantial number of employees (more than 5) being dismissed or intending to file for unemployment benefits during the proposed policy period?

Yes

No

If yes, explain a) How many full-time employees

b) How many part-time employees

c) Reason or cause for lay offs

6.

	Year	Total Claims Amount	Number of Involuntary Discharges	Number of Retirements	Number of Quits	Number of Lay offs
Please complete claims experience as follows for the current year-to-date:	Year	Total Claims Amount	Number of Involuntary Discharges	Number of Retirements	Number of Quits	Number of Lay offs

7. Total number of employees currently on staff: Full Time

Part Time

8. Indicate anticipated percentage of increase or decrease in staff for coming year:

Percentage Increase

Percentage Decrease

This application, duly completed, together with any supplementary information must be signed in ink by the applicant. A signed copy will be attached to and becomes part of insurance policy if issued. Completion of this Application does not bind the applicant or Underwriters to complete the insurance. (I/We) hereby declare, based upon (my/our) knowledge and upon reasonable investigation, the above statements are true and that (I/we) have not suppressed or misstated any material facts on this application. All information disclosed on this application together with any supplementary information obtained regarding the applicant shall be considered proprietary and remain in the exclusive control of the named insured and the insurer.

Date +

Executive Director or Finance Director

Electronic Signature *

Title

Mail signed and dated application to

Complete Equity Markets, Inc.
In California dba Complete Equity Markets Insurance Agency, Inc.
1190 Flex Court
Lake Zurich, Illinois 60047
Toll Free (800) 323-6234
In Illinois (847) 541-0900
Fax (847) 541-0444
bslawin@cemins.com

AIF 2078 AR-NP (09/08) THIS DOCUMENT MUST NOT BE DUPLICATED