Employment Practices Liability Insurance Quote Request

Your Full Name (required)

Company Name:

Address:

City:

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Zip Code:

Business Phone Number: (required)

Business FAX:

Your Email: (required)

Employee Information

No. of F-T Employees:    No. of P-T Employees:

No. of Employees within Salary Range:

$1-30K:    $30K-50K:    $50K-100K:    > $100K:

Prior/Pending Claims

Within the past 5 years, has any administrative hearing / claim been made or is now pending against the organization?

YesNo

Is any person aware of any fact or circumstance that may give rise to a claim under this policy?

YesNo

Operations/Procedures

Nature of Operations:

Does the insured have written policies/procedures on?

Hiring/Firing: YesNo

Sexual Harassment: YesNo

Discrimination: YesNo

Is there a Human Resource Department? YesNo

Miscellaneous Information

Has there been, or is there anticipated to be any reduction in staff in the past / future 12 months? If YES, explain: YesNo

Does the Insured have an "Employment At Will" statement? YesNo

Does the handbook state that it is "not a contract"? YesNo

Is EPL coverage in place currently? If YES: YesNo

a) Inception date of first policy:

b) Current Carrier:

Claims

Any claims in last 3 years? YesNo

If Yes, please describe.

Additional Comments or Questions:

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