Zolofra Insurance
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Toll Free: (888) 858-1777
Fax: (732) 334-0405
Email: Ben@allprocoverage.com





Name of Business (as it should appear on policy)

Contact Name

Company’s Website

Address

City

County

State

Zip Code

Contact Phone Number

Fax Number

Contact Email Address

Services offered by the business

Is your business currently covered by an Employment Practices Liability Insurance (EPLI) Policy?

Name of Current Carrier

Expiration Date (mm/dd/yyyy)

Total number of employees, including owners, partners, officers, and directors

Non union employee breakdown:

Full-Time:

Part-Time:

Temporary:

Seasonal:

Union employee breakdown:

Full Time:

Part Time:

Temporary:

Seasonal:

Total number of persons employed in each of the last 3 years:

This Year:

Last Year:

2 Years Ago:

If applicable, list all additional locations by city and state and indicate the number of employees at each location.

Any EEOC complaints, NLRB charges or lawsuits been made against you by any current or former employees within the past 5 years?

If yes, provide the date, description and total amount of each loss.

Are you aware of any facts, incidents or circumstances which may result in any Employment Practices Liability losses, claims or suits being made against them?

If yes, please provide details

Are any plant, facility, branch, office closings or layoffs anticipated within the next 24 months?

If yes, please provide details:

Desired Limits:

 100,000/100,000 250,000/250,000 500,000/500,000 1,000,000/1,000,000 2,000,000/2,000,000

Desired Deductible:

 2,500 5,000 7,500 10,000 15,000 25,000

Select which of the following are distributed to all employees:

 Employee Manual Sexual Harrassment Statement Equal Opportunity and Discrimination Statement Employee Grievance Procedures Discipline Procedures

Is there an employment application used for all applicants?

Are annual written performance evaluations conducted for all employees?

Would you like coverage for wrongful acts that take place outside the USA, it’s territories and possessions, Puerto Rico or Canada and Coverage for claims made against you by leased workers and independent contractors?

If yes, what percentage of your workforce is comprised of leased workers?

What percentage of your workforce is comprised of independent contractors?

How did you hear about us?

Additonal Comments:

Disclaimer Notice – The premiums quoted are estimates based on information you provided. This quotation does not constitute a contract of insurance, nor does it provide coverage for any loss or claim. Coverage can only be bound by an agent with a signed application and a down payment.

Please utilize the “Send” Button to send your form to our office. If the website does not allow you to submit the form, please print the page and fax it to 732.334.0405 or scan it into your computer and send it to ben@allprocoverage.com. Do not “Refresh” the page because all data entered onto the form will be lost.

After you hit the “Send” button, please scroll back down to this area and if successfully sent, a message will appear below. If not successfully sent, a message will appear below which means you have to scroll back up and complete the missing information, which typically involves entering information into a highlighted box. Complete the missing information and then hit “Send” again. Thank you!

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Zolofra Insurance Agency
P.O. Box 8787
Red Bank, NJ 07701
Toll Free: (888) 858-1777
Direct: (732) 542-1757
Fax: (732) 334-0405
Email: Ben@allprocoverage.com
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