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Employment Practices Liability Insurance (EPLI)

Safeguard your company, executives, and balance sheet against the rising cost of employee lawsuits, wrongful termination allegations, and discrimination claims.

Employment Practices

First Name

Last Name

Formal Name of Business

Business Type

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

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