1.     Full legal name of Insured:

2.     Principal business premise address:

(Street)

        City State Zip  County

3.     Date organized (mm/dd/yyyy):

4.     Full description of business operations:

5.     Number of employees for all locations:

State

Full-Time
(Regular)

Part-Time
(Regular)

Full-Time
(Leased/Seasonal/Temp)

Part-Time
(Leased/Seasonal/Temp)

                          NOTE: Include all Directors, Officers, Partners and Employees

6.     Provide the number of employees:

        (a) Involuntarily terminated during the last twelve months:

        (b) Voluntarily terminated during the last twelve months:

  YES NO
7.     Do you have a personnel or human resources department?  
8.     Do you have an employee manual that states your right to terminate employment at will?
9.     Are all the proper notification posters required by the EEOC prominently displayed?
10.   (a)    Any recent or anticipated lay-offs or staff reductions?

(b)    Any recent or anticipated merger or acquisition activity?

(c)    Any recent or anticipated plant/office relocations or closures?
11.  Was the employee turnover greater than 20% in one or more of the past five years?
12.  How many Employment Practices claims or EEOC/State Agency charges have been filed    
       against any proposed insured over the past five (5) years?  

If applicable, please attach a detailed explanation to include primary allegations, status, indemnity and expense amounts reserved and/or paid.

    
  YES NO
13. Are you aware of any present situation that may result in a claim within the next year?

If yes, please attach a detailed explanation.

    
14. Is Third Party Coverage desired?

If yes, please complete a Third Party Coverage Supplement.

    
15. Do you presently have EPL coverage?

If yes, provide the following:

    

 

Policy Period Insurer Deductible Premium Prior Acts Date Co-Pay
     

 

16. Desired Limit: Deductible: Prior Acts Date:

THIS APPLICATION ALLOWS THE INSURER TO ESTIMATE A PREMIUM BUT DOES NOT COMMIT THE INSURER OR APPLICANT TO ENTER INTO ANY INSURANCE CONTRACT. IN ORDER TO OBTAIN A QUOTE, YOU MUST COMPLETE THE STANDARD APPLICATION.

This application was completed by: Agency:

e-mail: fax: 

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