Directors & Officers Application Form for IAFF Affiliates 2022 – California Contact Email:(Required) Organization name:(Required) Address:(Required) Street Address City State / Province / Region ZIP / Postal Code Website:(Required) # W2 paid EEs - NOT officers:(Required) Annual Revenue:(Required) # of Voting Officers:(Required) Local #:(Required) # of Members:(Required) Requested inception date:(Required) Month Day Year In order to confirm eligibility for the program, can you confirm that the below statements are true:(Required) Yes No You are a private company or have tax exempt status as defined by the Internal Revenue Agency. You are a current member of the International Association of Fire Fighters Assn.. You have made a profit in the last 12 months (Not applicable to non-profits.). You have a positive net worth in your latest annual financial statements. In the past 24 months there have been no employee layoffs. You have written grievance and disciplinary procedures which are communicated to all employees. You distribute an employee handbook to all employees. There have been no claims made against the company, organization or any person proposed for Insurance in the capacity of either past or present director, officer, trustee, volunteer or employee acting in a managerial or supervisory capacity of the company or organization. After enquiry, neither you or your directors, officers, trustees, volunteers or employees are aware of any fact, circumstance, allegation, or incident that might give rise to a claim under the proposed policy. Declaration I declare that after proper enquiry the statements and particulars given above are true and that I have not mis-stated or suppressed any material fact. I agree that this application form, together with any other material information supplied by me shall form the basis of any contract of insurance effected thereon. I undertake to inform underwriters of any material alteration to these facts occurring before completion of the contract.Full name:(Required) Position:(Required) Signature:(Required)Date:(Required) Month Day Year THE SIGNING OF THIS APPLICATION DOES NOT BIND THE APPLICANT OR THE INSURER TO COMPLETE THE INSURANCE, BUT IT IS AGREED THAT THIS APPLICATION SHALL BE THE BASIS OF THE CONTRACT SHOULD A POLICY BE ISSUED. IF THE INFORMATION SUPPLIED ON THIS APPLICATION CHANGES BETWEEN THE DATE OF THIS APPLICATION AND THE INCEPTION DATE OF INSURANCE, PLEASE IMMEDIATELY NOTIFY THE INSURER OF SUCH CHANGES. THE INSURER MAY WITHDRAW OR MODIFY ANY OUTSTANDING QUOTATIONS, AUTHORISATIONS OR AGREEMENTS TO BIND THE INSURANCE. ALL WRITTEN STATEMENTS AND MATERIALS FURNISHED TO THE INSURER IN CONJUNCTION WITH THIS APPLICATION ARE HEREBY INCORPORATED INTO THIS APPLICATION.PhoneThis field is for validation purposes and should be left unchanged.