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.

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):

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?

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?

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

Employment Practices Liability Online Application

Personal Information

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