Employment Practices Liability (EPLI) Quote
General Information
Page 1 of 2
Company Name
*
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Contact Name
*
First Name
Last Name
Title
Phone Number
-
Area Code
Phone Number
E-mail
*
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Underwriting / Rating Information
Page 2 of 2
Type of Business
*
Number of years in operation
*
Please Select
Less than 3 years
More than 3 years
Breakdown of Employees By State
*
Including all salary and commissions, do 5% or more of the company’s employees earn over $100,000 annually or does any one employee earn over $250,000 annually (do not include the owner(s) when answering the question)?
Yes
No
Has the company laid-off (excluding seasonal layoffs) or terminated more than 30% of its workforce in the past 12 months?
Yes
No
Does the company anticipate any layoffs (excluding seasonal layoffs), downsizing or office or plant closings in the next 12 months?
Yes
No
Within past 3 years, has company had any lawsuits, threatened claims, or charges filed with the EEOC or state/local administrative agency involving a Wrongful Employment Act, or Third Party Wrongful Act?
Yes
No
[NEW APPLICANTS ONLY] Does any director, officer, owner, member, or partner of the company have knowledge of any fact, circumstance, or situation which may result in a Claim, such as would fall under the proposed insurance?
Yes
No
Does the company currently have AND regularly distribute the following written policies? (Check all that applies)
Harassment
Discrimination
Employment at will Statement
Does the company currently carry Employment Liability Insurance (EPLI) coverage?
Yes
No
Currentt Insurer:
Current Limit of Liability:
Please Select
Less than 100,000
100,000
250,000
500,000
1,000,000
2,000,000
3,000,000
4,000,000
5,000,000
Other
Current Retention:
Please Select
2,500
5,000
7,500
10,000
15,000
20,000
25,000
50,000
More than 25,000
Other
3rd Party Coverage:
Please Select
Yes
No
Defense Outside the Limit:
Please Select
Yes
No
Policy Expiration Date:
-
Month
-
Day
Year
Date Picker Icon
Date of First Policy or Coverage:
-
Month
-
Day
Year
Date Picker Icon
Is Coverage Endorsed to a Commercial Policy?
Please Select
Yes
No
Submit
Should be Empty: