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

Hold down the Ctrl Key to make multiple selections.

Additional Comments

Optional

Submission Validation

Required

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.

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Oakhurst, NJ 07755