Simplified
EPL
Insurance Quote

 		 We would like to provide you with a free, no-obligation insurance quote. Please provide as much information as possible to obtain the most accurate quote. This information will be kept confidential and will be used for quote purposes only.

General Information
Name of Insured:
Address:
City:
   
State:
Zip:
Business Phone:
 
Business Fax Number:
Email Address:
Year Organized:
Does Insured Have Any Subsidiaries?
Yes   No     If YES, STOP... please call to discuss this with one of our representatives

 

Employee Information
# of Full Time Employees:
# of Part Time Employees:
# of Employees within Salary Range:
$1-30,000  
$30,001-50,000
$50,001-100,000
$100,001-greater

 

Prior/Pending Claims
Within the last 5 years, has any administrative hearing / claim been made or is one now pending against the organization?
Yes
No
Is any person aware of any fact or circumstance that might give rise to a claim under this policy?
Yes
No

 

Operations/Procedures
Nature of
Operations:
Does the insured have written policies / procedures on:
Hiring/Firing   Yes   No
Sexual Harassment Yes   No
Discrimination Yes   No
Is there a
Human Resource
Department?
Yes No

 

Miscellaneous Information
Has there been, or is there any anticipation of a reduction in staff over the past / future 12 months?   If YES, explain:
Yes
No
Does the Insured have an "Employment At Will" statement?
Yes
No
Does the handbook state that it is "not a contract"?
Yes
No
Is EPL coverage currently in place ?   If YES:
Yes
No
a) Inception date of first policy:   b) Current Carrier:

 

Additional Comments
Please make any additional comments you feel may be appropriate for this quote.


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One of our representatives will respond to your submission as soon as possible.