Employment Practices Liability Quote Form

GENERAL INFORMATION

Name of Applicant: *

Address: *

Phone: *

Website

Date Business Established

Sate of Incorporation / Formation:

Company Type (Corp / LLC / Sole Prop):

Please describe the nature of the Applicant's operations:

FEIN:

Provide a list of owners and percentage of ownership:

Name 1:

Percent Owned by Applicant:

Title:

Name 2:

Percent Owned by Applicant:

Title:

Name 3:

Percent Owned by Applicant:

Title:

Name 4:

Percent Owned by Applicant:

Title:

EMPLOYMENT PRACTICES INFORMATION

Existing EPLI Policy In Force / Active *

Yes

No

Employment Practices Liability Insurance has been continuously in force since:

Current Company

Current Policy Renewal Date

Please provide the following employee count information:

Full Time Employees *

Part Time Employees *

Volunteer / Donated Labor *

Any Seasonal Labor / Seasonal Increase or Decrease In Employment

Any 1099 Independent Contractors (If So Please Explain)

Total number of current employees with annual compensation greater than $ 100,000

How many employees have been terminated in the past 12 months?

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

Yes

No

If yes please provide details

Does the applicant anticipate any plant, facility, branch, office or department closing consideration, reorganization or layoff within the next twenty four (24) months?

Yes

No

If yes, please provide details:

Human Resource Policies and Procedures:

Does the Applicant:

have a standard employment application for all applicants?

Yes

No

have an employment handbook?

Yes

No

have an "At Will" provision in the employment application?

Yes

No

have a written policy with respect to sexual harrsment?

Yes

No

have a written policy with respect to discrimination?

Yes

No

have a written policy with respect to discrimination?

Yes

No

have written annual evaluations for employees?

Yes

No

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?

Yes

No

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?

Yes

No

Claim / Warranty Section

Has the applicant for this insurance been involved in any of the following?

Any discriminatory practice violation or litigation?

Yes

No

Any disciplinary action by any regulatory agency or association?

Yes

No

Please provide an explanation if question is answered yes.

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?

Yes

No

If yes please explain

ADDITIONAL INFORMATION

This section may be used to provide additional information to any question on this application.

Upload of any underwriting documents (Loss Runs / Current Policy Pages / Etc.)