BUSINESS OWNERS PROGRAM
Employment Practices Liability Quote Request
1
 Contact Information
 
 Name of Business
 
 Contact Name:
 
 Address:
 
 Address 2:
 
 City - St - Zip:
 
 Phone Number:       FAX
 
 E-Mail Address:
2
 Current number of Employees, including owners, partners, officers and directors for the Headquarter state.

Non-Union:
Full-Time
Part-Time
Temporary
Seasonal
Union:
Full-Time
Part-Time
Temporary
Seasonal
3
 Total number of persons employed by the applicant in each of the last 3 years (all locations).
Year
Number of Emplyees
4
 Total Number of employees that were terminated by the business and the total number of employees that voluntarily left their employment in the past three years (all locations)
Year
Terminated
Voluntarily Left
5
 If applicable, list all additional locations by city and state and indicate the number of employees at each location.
6

Have any EEOC complaints, NLRB charges or lawsuits been made against you by current or former employees within the past five years?

YES NO

If yes, please describe.
Year
Description
Total Amount of Loss
7
Is the applicant aware of any facts, incidents or circumstances which may result in any Employment Practices Liability losses, claims or suits being made against them?
YES NO
If yes, please provide details.
8
 Are any plant, facility, branch or office closings or layoffs anticipated within the next 24 months?
YES NO
If yes, please provide details.
9
 Desired Limits: (Each Wrongful Employment Act / Aggregate) (other limits may be available upon request)

$100,000/$100,000
$250,000/$250,000
$500,000/$500,000
$750,000/$750,000
$1,000,000/$1,000,000
$2,000,000/$2,000,000
10
 Desired Deductible: (Each Wrongful Employment Act)
$2,500
$5,000
 $7,500
$10,000
$15,000
$200,000
 $25,000
11
 Is your business currently covered by an Employment Practices Liability policy?
YES NO
12
 Are the following published and distributed to all employees:
  a) Employee Manual?
YES NO
  b) Sexual Harassment Statement?
YES NO
  c) Equal Employment and Discrimination Statement?
YES NO
  d) Employee Grievance Procedures?
YES NO
  e) Discipline Procedures?
YES NO
13
 Is there an employment application used for all applicants?
YES NO
14 Are annual written performance evaluations conducted for all employees?
YES NO
15 Please indicate whether the following optional coverages are desired:
  a) Coverage for Wrongful Acts that take place outside of the United States of America, it’s territories and possessions, Puerto Rico, or Canada; and Coverage for claims made against you by leased workers and independent contractors?
 
YES NO
  If yes, what percent of your workforce is comprised of leased workers and independent contractors
  b) Coverage for Punitive Damages; and Increased limits for earnings lost from $100 to $1,000 per day?
 
YES NO