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Employment Practices
Employment Practices
First Name
Last Name
Formal Name of Business
Business Type
- Select Business Type -
Sole Proprietor
LLC
Incorporated
Partnership
Professional Association
Street
City
State
ZIP / Postal Code
Primary Phone Number
Website Address
Email
Year Established
Description of Operations
Number of full-time employees
Number of part-time employees
Number of temporary/ seasonal employees
Number of independent contractors
Leased
How many of the above are located in California?
How many of the above are located in Florida?
How many of the above are located in Louisiana?
How many of the above are located outside the USA?
Do more than 50% of all employees currently earn more than $100,000?
Yes
No
Is the applicant a subsidiary of another organization?
Yes
No
Is the applicant a franchisee of another organization?
Yes
No
Name of parent and/or franchisor and location.
Does the applicant want any subsidiary(ies)/affiliate(s) covered? If “yes,” include employees in employee count above and provide:
Yes
No
Name of subsidiary(ies)/affiliate(s):
s the subsidiary(ies)/affiliate(s) at least 50% owned by the applicant?
Yes
No
Does the subsidiary(ies)/affiliate(s) fall within the same class of business as the applicant?
Yes
No
Has any entity proposed for insurance closed, sold, merged with or acquired any company in the past 12 months or anticipates doing so in the next 12 months?
Yes
No
Has any entity proposed for insurance downsized, laid off or reduced staff in the past 12 months or anticipates doing so in the next 12 months?
Yes
No
If “yes,” what percentage of the workforce was/will be affected?
Within the last five years, has any employment related, third party discrimination, or third party harassment inquiry, complaint, notice of hearing, claim or suit been made against any entity proposed for insurance?
Yes
No
Is any person proposed for this insurance aware of any fact, circumstance, or situation which may result in an employment related, third party discrimination, or third party harassment claim against any entity proposed for insurance?
Yes
No
Has any policy for employment practices liability insurance ever been cancelled or non-renewed by the carrier?
Yes
No
Check all that apply. You
- Select -
have a written e-mail/internet policy in place OR
agree to implement a written policy within 60 days
have a written anti-discrimination policy in place
agree to implement a written policy in 60 days OR
have a written anti-harassment policy in place
agree to implement a written policy within 60 days
Additional Comments
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