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Employment Practices Liability Online Application


Fill out the following form as completely as possible. Once you have completed the form, click the Submit button to send your information. Your request will be handled promptly.

Personal Information
First Name
Required
Last Name
Required
Formal Name of Business
Required
Business Type
Required
Street
Required
City
Required
State
Required
ZIP / Postal Code
Required
Primary Phone Number
Required
Website Address:
Required
E-Mail Address
Required
Year Established
Required
Description of Operations:
Required
Number of full-time employees
Required
Number of part-time employees
Required
Number of temporary/ seasonal employees
Required
Number of independent contractors
Required
Leased
Required
How many of the above are located in California?
Required
How many of the above are located in Florida?
Required
How many of the above are located in Louisiana?
Required
How many of the above are located outside the USA?
Required
do more than 50% of all employees currently earn more than $100,000?
Required
Is the applicant a subsidiary of another organization?
Required
Is the applicant a franchisee of another organization?
Required
Name of parent and/or franchisor and location.
Optional
Does the applicant want any subsidiary(ies)/affiliate(s) covered? If “yes,” include employees in employee count above and provide:
Required
Name of subsidiary(ies)/affiliate(s):
Optional
Is the subsidiary(ies)/affiliate(s) at least 50% owned by the applicant?
Required
Does the subsidiary(ies)/affiliate(s) fall within the same class of business as the applicant?
Optional
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?
Required
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?
Required
If “yes,” what percentage of the workforce was/will be affected?
Optional
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?
Required
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?
Required
Has any policy for employment practices liability insurance ever been cancelled or non-renewed by the carrier?
Required
Check all that apply. You
Required


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Additional Comments
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Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

Per the terms of our online privacy policy we will not resell your information to any third-party.
Location
Mailing Address Only
P.O. Box 868
Oakhurst, NJ 07755
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