Rockwood EPLI Quick Quote Questionnaire

EVEN A FRIVOLOUS EPLI CLAIM REQUIRES A DEFENSE
EPLI Program Features:
- Third Party Wrongful Act
- Wage and Hour
- Full Prior Acts available
- Advocacy claims defense provided by nationally recognized experts
Company Name *
Address *

Address

Street Address Line 2

City State

Zip
Number of years in business *
Business class *
Full Time Employees *
Part Time Employees *
Have you had an EPLI loss in the past 5 years:

Yes No
If “Yes”, please provide details below:
Do you have an employee handbook?

Yes No
Wage/Hour:

Yes No
Defense Outside the Limits:

Yes No
Do you currently have EPLI coverage?

Yes No
Please provide current policy information
Limit: $
Retention: $
Premium: $
Retro Date

Month Day Year
Date
This section to be completed by Insurance Agent:
Agency Name/Agent *
Email Address *
example@example.com
Phone Number *
Please enter a valid phone number.
Address *

Street Address

Street Address Line 2

City State

Zip Code
SUBMIT FOR A QUICK QUOTE!
Should be Empty:

EVEN A FRIVOLOUS EPLI CLAIM REQUIRES A DEFENSE