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:

YesNo
If “Yes”, please provide details below:
Do you have an employee handbook?

YesNo
Wage/Hour:

YesNo
Defense Outside the Limits:

YesNo
Do you currently have EPLI coverage?

YesNo
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.
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