Employment Practices Liability Application for Quote

(* required information)

General Information
Name of Applicant
Email Address*
Mailing Address 1
Mailing Address 2
City
State		AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY
Zip Code
List ALL Locations
Name Location Address # FT Employees # PT Employees # Seasonal Employees
Business Operations			Date Established (MMDDYY)
Annual Revenue (Past 3 Years)		$   $   $
Type of Business		Select One Corporation Partnership Individual Other
List all claims involving allegations of wrongful termination, discrimination, or sexual harrassment during the past 5 years. If there have been no such claims, please print "none".
Date of Claim (MMDDYY) Claiment Nature of Claim Defense Costs Indemnity Costs Status
Is the applicant, its' officers, or senior administrative personell aware of any fact, incident, or situation which may be reasonably expected to give rise to a claim within the scope of the proposed policy?					yes no
Do Family Members Operate Vehicle?		yes no
If Yes, please     explain
In the past 5 years has the applicant been involved in any charges, inquiries, investigations, grievances, or administrative hearings before any of the below agancies and/or in regards to any of theacts listed below:
National Labor Relations Baard yes no U.S., Department of Labor yes no Equal Employment Opportunity Commission yes no Americans with Disabilities Act yes no Fair Labor Standards Enforcment Act yes no Age Discrimination Act yes no Title VII of the Civil Rights Act yes no Civil Rights Act of 1991 yes no Family Medical Leave Act yes no
Current Employment Practices Liability Insurance Information
Insurer Policy Inception Date (MMDDYY) Limits Policy Expiration Date (MMDDYY) Premium Retroactive Date (MMDDYY)
Has the applicant completed any merger, acquisition, or consolodation within the last 24 months?					yes no
Does the applicant contemplate any merger, acquisition, or consolodation in the next 24 months?					yes no
Has the applicant experienced any layoffs, reductions in force, or reorganization with the last 24 months?					yes no
Does the applicant anticipate any layoffs, reductions in force, or reorganization with the next 24 months?					yes no
Number of Employees under age 40			Number of Employees over 40
Number of employees by salary range Under $25,000 $25,000 - $75,000 Over $75,000
For each of the past 3 years compute the annual turn-over of employees (calculated as the number of separations during the year divided by the average number of employees on the payroll for each year 2001 2002 2003
Does the applicant have a Human Resource or Personnel Department?					yes no
If yes, please list     name, title, and     phone number
Please list the name, title, and telephone number of the appropriate risk management contact for this insurance:
Does the applicant use an employment application for all applicants for hire?					yes no
Does the applicant have an employee handbook?					yes no
Is the handbook distributed to all employees?					yes no
Does the applicant have a written affrimative action plan?					yes no
Has the plan been updated in the past 12 months?					yes no
Does the applicant have a written anti-harassment policy?					yes no
If not, is the applicant willing to implement a written anti-harassment policy?					yes no
Is there a written pay program, including pay ranges, for the organization?					yes no
Is there an established internal dispute resolution or grievance process?					yes no
Is ther a written disciplinary process?					yes no
Is there a written performance appraisal process?					yes no
Are all employees evaluated annually?					yes no
Are employee terminations reviewed by Human Resources?					yes no
Does the applicant have written policies for Americans with Disabilities Act?					yes no
Does the applicant have Federal contracts or serve as a subcontractor on contracts over $50,000 per year?					yes no