Standalone EPLI Quote
What is the Nature of Business (NOB)?
*
Type a question
Please Select
Total Payroll/Expense
*
Enter in Company's total annual salary/payroll
Named Entity's State
*
Total Number of Full Time Employees
*
Total Number of Part Time Employees
*
Number of Independent Contractors
*
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Additional Company Info
Legal Name of the named entity to be named in item #1 in the declarations:
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Company Website
*
Please enter all DBA names, separated by semi-colon
Physical Company Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Is the mailing address the same as the physical address above?
*
Yes
No
Company Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Business Type:
*
Please Select
LLC
Sole Proprietorship (individual)
Corporation
Partnership
Other
Ownership Structure
*
Please Select
Privately Held
Publicly Traded
Not-for-Profit
Governmental
How many Years has the entity been in Operation?
*
Owned by a foreign parent?
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Yes
No
Is the Company a Franchisee or Franchisor?
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Yes
No
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Current Insurance Info
Does the named insured currently have EPL coverage?
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Yes
No
Insurer:
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Limit:
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Policy Expiration Date:
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-
Month
-
Day
Year
Date
Deductible Amount:
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Premium:
*
Prior & Pending Litigation Date:
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-
Month
-
Day
Year
Existing dec pages & loss runs needed to match expiring.
Retroactive Date:
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-
Month
-
Day
Year
Existing dec pages & loss runs needed to match expiring.
Has EPL coverage ever been canceled or nonrenewed for the insured? (if yes, quote will be referred to an underwriter)
*
Yes
No
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Additional Entities
Requesting Coverage for Additional Entities?
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Yes
No
Please provide the ownership of the Named Entity named in the Company Info Section
Name(s) of the Named Entity's Owner(s)
*
First Name
Last Name
% of Ownership
*
Add another owner?
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Yes
No
Name(s) of the Named Entity's Owner(s)
*
First Name
Last Name
% of Ownership
*
Add another owner?
*
Yes
No
Name(s) of the Named Entity's Owner(s)
First Name
Last Name
% of Ownership
Add another owner?
Yes
No
Name(s) of the Named Entity's Owner(s)
First Name
Last Name
% of Ownership
Additional Entity 1
All information provided in this section should be in reference solely to Additional Entity 1
Legal Name
First Name
Last Name
Zip Code
Enter each DBA name, separated by semi-colon
Nature of Business (NOB)
Full Time Employees
Part Time Employees
Independent Contractors
Name(s) of the Additional Entity's Owner(s)
First Name
Last Name
% of Ownership
Add another owner?
Yes
No
Name(s) of the Additional Entity's Owner(s)
First Name
Last Name
% of Ownership
Add another owner?
Yes
No
Name(s) of the Additional Entity's Owner(s)
First Name
Last Name
% of Ownership
Add another owner?
Yes
No
Name(s) of the Additional Entity's Owner(s)
First Name
Last Name
% of Ownership
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Employee Profile
Number of Full Time Employees (1 year ago)
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Number of Part Time Employees (1 year ago)
*
Number of Independent Contractors (1 year ago)
*
List the 3 states with the largest number of employees:
State
*
Number of Employees
*
State
Number of Employees
State
Number of Employees
Number of Employees working in California
Number of Employees that are employed outside of the United States
Does the Company (and any Additional Entities) have union employees?
Yes
No
Does the Company (and any Additional Entities) have any planned transactions or events , within the next 12 months, that would increase the number of current total employees stated above by more than 25%? (if yes, quote will be sent to underwriter)
Yes
No
Company's (and any Additional Entities’) total annual salary/payroll expense for the most recent year-end (including bonuses, commissions and owners’/officers’ compensation):
Company's (and any Additional Entities’) number of employees (including owners/officers) whose annual compensation (including bonuses and commissions) falls within each of the following ranges of $50,000 and above:
Company’s (and any Additional Entities’) historical average annual turnover rate:
20% or less
21%-35%
Greater than 35%
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Employee Profile (Continued)
Has the Company (and any Additional Entities) terminated any officers?
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Yes
No
Name of Officer
*
First Name
Last Name
Date of Termination
*
-
Month
-
Day
Year
Date
Was severance provided, or will it be provided, to this officer? (if no, quote will be sent to manual underwriting)
Yes
No
Release from liability obtained, or will be obtained, from this officer?
Yes
No
Has the Company (and any Additional Entities) had any layoffs or early retirement programs?
Yes
No
Has the Company (and any Additional Entities) been involved in any of the following within the past 12 months, or considering being involved in any within the next 12 months:
Merger, acquisition or divestment activity?
Yes
No
Bankruptcy proceeding or financial restructuring?
Yes
No
Change in ownership structure?
Yes
No
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Litigation Info
During the past five years, has the Company (and any Additional Entities) or any person proposed for this insurance, in their capacity as either Director, Officer, member of the Board of Managers, or employee of the Company (and any Additional Entities): -Received any written demands for monetary or non-monetary relief OR -Been involved in any civil, criminal, administrative or arbitration proceeding involving:
Any current or former employee alleging discrimination, harassment, wrongful discharge and/or any wrongful employment act?
Yes
No
The Equal Employment Opportunity Commission (EEOC) or other similar state or local agency?
Yes
No
Any actual or alleged violations of any “wage and hour” labor laws, including the Fair Labor Standards Act (FLSA) or any similar state or local law?
Yes
No
The National Labor Relations Board (NLRB)?
Yes
No
The U.S. Immigration and Customs Enforcement Agency (ICE)?
Yes
No
Any customer, client or other third party alleging harassment, discrimination, or civil rights violations?
Yes
No
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Knowledge Info
With respect to Employment Practices Liability Coverage, it would be reasonable to foresee that an Employment Practices Claim may be brought if a current or former employee (including officers), or an applicant for employment, has expressed dissatisfaction with the employment relationship or the employment application process by: Complaining of discrimination, harassment, or unfair treatment and threatening to pursue further; Asking for a severance package in excess of what was offered; Threatening to hire an attorney; or Making a formal complaint to an owner, officer or supervisory employee of unfair employment practices. With respect to Third Party Liability Coverage, it would be reasonable to foresee that a Claim may be brought if a customer, client, supplier, distributor, independent contractor or other individual or group of individuals who are not employees but have expressed dissatisfaction by: Complaining of sexual harassment and threatening to pursue further; or Making a formal complaint of discrimination to an owner, officer or supervisory employee.
Knowledge Question: Is the undersigned or any Director, Officer or member of the Board of Managers proposed for this insurance aware of any fact, circumstance or situation involving the Company (and any Additional Entities), Director, Officer or member of the Board of Managers which he or she has reason to believe might result in any future Employment Practices Claim under the policy to which this Proposal Form will be attached?
*
Yes
No
Please provide a description:
*
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Agent Info (Your Info)
Name
*
First Name
Last Name
Agency Name
*
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Submit
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