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National Federation of Press Women Form

National Federation of Press Women

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APPLY NOW

NATIONAL FEDERATION OF PRESS WOMEN NEWS MEDIA LIABILITY INSURANCE PROGRAM MEMBER ELIGIBILITY STATEMENT

NOTICE: THE POLICY IS WRITTEN ON A CLAIMS-MADE BASIS. THE POLICY PROVIDES THAT THE LIMITS OF LIABILITY AVAILABLE TO PAY JUDGMENTS OR SETTLEMENTS WILL BE REDUCED AND MAY BE EXHAUSTED BY “DEFENSE EXPENSES” AND “SUBPOENA DEFENSE EXPENSES.” “DEFENSE EXPENSES” AND “SUBPOENA DEFENSE EXPENSES” WILL BE APPLIED AGAINST THE APPLICABLE RETENTION.

Your Name*

Address*

Street Address City State / Province / Region ZIP / Postal Code

Email*

Fax

Telephone*

Number of years engaged in professional writing or other professional press activities?_*

Are you currently a Premium member in good standing of the National Federation of Press Women?*

Date of initial NFPW membership?

Please describe the nature of the activities to be insured. (A sample may be requested)*

Ineligible activities:

Fiction or non-fiction book authors. Publishers or editors of books, magazines, newspapers or newsletters. Website owners or Internet Service Providers. Applicants with gross revenues of $200,000 or more.

In the last year, what was your total income (before taxes) from all professional writing, speaking, broadcasting, or other professional press activities?*

In the past three (3) years, have you been named as a defendant in any suit and out of your professional press activities, including but not limited to suits for libel, slander, invasion of privacy or misappropriation of name or likeness, infringement of copyright or trademark, infliction of emotional distress, false arrest, wrongful entry, or trespass?*

Yes

Please list the three (3) major clients for whom you provide or expect to provide professional writing, speaking, broadcasting, or other professional press services in the following twelve (12) months.*

Please list an website for which you regulary provide or expect to provide content in the following twelve (12) months.*

THE UNDERSIGNED DECLARES THAT TO THE BEST OF HIS/HER KNOWLEDGE AND BELIEF, AFTER REASONABLE INQUIRY, THE STATEMENTS HEREIN ARE TRUE AND COMPLETE.. THE INFORMATION CONTAINED IN AND SUBMITTED WITH THIS STATEMENT IS ON FILE WITH THE UNDERWRITER AND ALONG WITH THE STATEMENT IS CONSIDERED PHYSICALLY ATTACHED TO THE POLICY AND WILL BECOME A PART OF IT. THE UNDERWRITER WILL HAVE RELIED UPON THIS STATEMENT AND ATTACHMENTS IN ISSUING ANY POLICY AND ENDORSEMENTS THERETO. IF THE INFORMATION IN THIS STATEMENT MATERIALLY CHANGES BETWEEN THE DATE OF THIS STATEMENT AND THE POLICY EFFECTIVE DATE, THE APPLICANT WILL NOTIFY WALTERRY INSURANCE BROKERS, AND SUCH INFORMATION MAY EFFECT ELIGIBILITY IN THIS PROGRAM.

ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES A STATEMENT FOR INSURANCE CONTAINING ANY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND MAY SUBJECT SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES.

Your typed name in the signature box confirms the accuracy of the information within this form and becomes legally binding.*

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National Federation of Press Women Form