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
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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
*
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:
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:
2,500
5,000
7,500
10,000
15,000
20,000
25,000
50,000
More than 25,000
Other
3rd Party Coverage:
Yes
No
Defense Outside the Limit:
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?
Yes
No
Submit
Should be Empty: