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

CityState

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:
If “Yes”, please provide details below:
Do you have an employee handbook?
Wage/Hour:
Defense Outside the Limits:
Do you currently have EPLI coverage?
Please provide current policy information
Limit: $
Retention: $
Premium: $
Retro Date

MonthDayYear
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.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState

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

EVEN A FRIVOLOUS EPLI CLAIM REQUIRES A DEFENSE