EPLI Insurance Quote
Name
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First Name
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Company Name
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Company Name
Business Description
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Business Description
Address
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Street Address
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BACKGROUND
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Is coverage being requested for any "additional entities" (Subsidiaries or affiliates of the Company)?
Yes
No
If yes, Does the Company own more than 50% of the voting stock of all the "additional entities"?
Yes
No
N/A
If "yes", please provide the full, legal names of the additional entities.
If no, Are all of the "additional entities'· related to the Company through common majority ownership?
Yes
No
N/A
ls the primary class of business for the Company or any "additional entities" any of the following classes? Labor Unions Government/Public Administration Tobacco Mortgage REIT Employment Placement AgencyGuns/Firearms Law Firms Securities Brokers/Dealers Investment Banking
Yes
No
If No please explain
Years in operation
*
Less than 3 years
3-5 years
more than 5 year
Breakdown of the # of employees (including temporary, seasonal, and leased employees) for the Company and "additional entities")
*
Average salary expense for the most recent year-end for the Company and "additional entities":
$25,000 or less
$25,001-$50,000
$50,001-$75,000
greater than $75,000
Historical average annual turnover rate for the Company and "additional entities"
20% or less
21% - 35%
greater than 35%
Has the Company or any "additional entities" considered layoffs within the next 12 months, any layoffs or early retirement programs including those resulting from reorganizations or facility closings?
Yes
No
If yes when did layoffs occur and how many employees?
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PRIOR ACTIVITIES
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1. Have there been during the last five years, or arc there now pending, any employment related civil, criminal, administrative or arbitration proceedings (including any proceeding initiated before the Equal Employment Opportunity Commission) brought against the Company, "additional entities" or any person proposed for this insurance in their capacity as either Director, Officer, or employee of the Company or its "additional entities"?
Yes
No
Have there been during the last five years, or are there now pending, any criminal, administrative or arbitration proceedings by any customer, client or other third party against the Company,"additional entities", or any person proposed for this insurance alleging discrimination, sexualharassment or violations of civil rights based upon discrimination or harassment?
Yes
No
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PRIOR COVERAGE
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Is Employment Practices Liability Insurance (either on a stand-alone basis or incorporated into some other policy) currently purchased?
Yes
No
If Yes please include insurer, limit, prior & pending litigation date and policy period
Has any claim been made or has any notice been given to any insurer?
Yes
No
ls the signer of this application or any Director or Officer proposed for this insurance aware of any fact, circumstance or situation involving the Company or "additional entities" which he or she has reason to believe might result in any future Claim which would fall within the scope of the Increased Limit of Liability?
Yes
No
N/A
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Is the signer of this application or any Director or Officer proposed for this insurance aware of any fact, circumstance or situation involving the Company or "additional entities" 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
If "Yes", please provide a description of the fact, circumstance, and/or situation below:Is the signer of this application or any Director or Officer proposed for this insurance aware of any fact, circumstance or situation involving the Company or "additional entities" which he or she has reason to believe might result in any future claim brought by a customer, client or other third party against the Company, "additional entities", or any person proposed for this insurance alleging discrimination, harassment or violations of civil rights, based upon discrimination or sexual harassment, under the policy to which this Proposal Form will be attached?
If "Yes". please provide a description of the fact, circumstance, and/or situation below IT IS AGREED THAT IF KNOWLEDGE OF ANY SUCH, CIRCUMSTANCE OR SITUATION EXISTS, ANY CLAIM SUBSEQUENTLY ARISING THEREFROM SHALL BE EXCLUDED UNDER THE PROPOSED COVERAGE NOTICE TO ARKANSAS APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit, or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. NOTICE TO COLORADO APPLICANTS: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies. NOTICE TO DISTRICT OF COLUMBIA APPLICANTS: Warning: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was reported by the applicant. NOTICE TO FLORIDA APPLICANTS: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.
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