Employment Practices Liability Quote Form

GENERAL INFORMATION

Provide a list of owners and percentage of ownership:

EMPLOYMENT PRACTICES INFORMATION

Existing EPLI Policy In Force / Active *
Please provide the following employee count information:
Total Current Employee Count
0/100 points
Is any reduction of employees or change of status anticipated or being contemplated in the next year? If yes please provide number estimated and explanation for change
Does the applicant anticipate any plant, facility, branch, office or department closing consideration, reorganization or layoff within the next twenty four (24) months?
Human Resource Policies and Procedures:
Does the Applicant:
have a standard employment application for all applicants?
have an employment handbook?
have an "At Will" provision in the employment application?
have a written policy with respect to sexual harrsment?
have a written policy with respect to discrimination?
have a written policy with respect to discrimination?
have written annual evaluations for employees?
Third Party Policies and Procedures:
 
Does the Applicant:
have policies or procedures outlining employee conduct when dealing with customers, clients, vendors, the general public or other third parties, including non-discrimination and non-harassment statements?
have policies or procedures for responding to complaints of harrasment, discrimination, or civil rights violations from its customers, clients, vendors, the general public or other third parties?

Claim / Warranty Section

Has the applicant for this insurance been involved in any of the following?
Any discriminatory practice violation or litigation?
Any disciplinary action by any regulatory agency or association?
Has the applicant given notices of claims, specific facts or circumstances which might give rise to a claim under any prior policies providing similar insurance?

ADDITIONAL INFORMATION