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.
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Please complete the following questions.

1. Please indicate current funding sources and revenues

2. Is your budget fully funded for the proposed period of coverage?
4. Are there any changes in regulations or policies that you are aware of that could result in funding cutbacks and/or lay offs?
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?
6.
 YearTotal Claims AmountNumber of Involuntary DischargesNumber of RetirementsNumber of QuitsNumber of Lay offs
Please complete claims experience as follows for the current year-to-date:
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  (type or print)

                                                              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