Simplified EPL Quote
Fields marked (
*
) are mandatory.
General Information
Name of Insured *
Address *
City
State
Please select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip
Business Phone *
Fax Number
Email Address *
Year Organized
Does Insured Have Any Subsidiaries?
No
Yes
If YES, STOP... please call to discuss
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 past 5 years, has any administrative
hearing / claim been made or is now pending
against the organization?
No
Yes
Is any person aware of any fact or circumstance
that may give rise to a claim under this policy?
No
Yes
Operations/Procedures
Nature of Operations
Does the insured have written policies/ procedures on:
Hiring/Firing
No
Yes
Sexual Harassment
No
Yes
Discrimination
No
Yes
Is there a Human Re s ourc e Department?
No
Yes
Miscellaneous Information
Has there been, or is there anticipated to be any
reduction in staff in the past / future 12 months?
No
Yes
If YES, explain
Does the Insured have an "Employment At Will"
statement?
No
Yes
Does the handbook state that it is "not a contract"?
No
Yes
Is EPL coverage in place currently?
No
Yes
If YES
a) Inception date of first policy
b) Current Carrier
Additional Comments
Additional Comments