Employment Practices Liability Online Insurance Application

Name of Business

Contact Name

Company’s Website

Address

City

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?


Please Select Yes No

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?


Please Select Yes No

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?


Please Select Yes No

If yes, please provide details

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


Please Select Yes No

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?


Please Select Yes No

Are annual written performance evaluations conducted for all employees?


Please Select Yes No

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?


Please Select Yes No

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

What percentage of your workforce is comprised of independent contractors?

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@zolofrainsurance.com. Do not “Refresh” the page because all data entered onto the form will be lost.