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EMPLOYMENT PRACTICES LIABILITY INSURANCE QUOTE
Please fully complete the following data form, and simply click the "Submit" button and we will contact you with an insurance quotation.

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EMPLOYMENT PRACTICES LIABILITY INSURANCE

 

First Name:
Last Name:
Email Address:
Business Name:
Address:
City:
State:
Zip Code:
Phone Number:
Fax Number:
LOCATION DETAIL INFORMATION

Additional Business Address
F/T Employees
P/T Employees
Seasonal
Loc #1: Same Address As Above
Loc #2:
Loc #3:

UNDERWRITING INFORMATION

Please Describe the Nature of Your Business:

Type of Ownership:
Years of Experience:
Number of employees under age 40:
Number of employees over age 40:
Number of employees by salary range (under $25,000 year):
Number of employees by salary range ($25,000-$75,000 year):
Number of employees by salary range (over $75,000 year):
Number of employees that left the company (last year):
Number of employees that left the company (year before last):
How Many Years Have You Operated This Business:
Business License Number:
License Type:
This Years Estimated Gross Receipts:
Last Years Gross Receipts:
Year Before Last Gross Receipts:
Is This Business Open 24 Hours A Day?
 yes  no  
Are you aware of any claim situation not filed?
 yes  no  
Any inquiries from the National Labor Relations Board?
 yes  no  
Any inquiries from the Equal Employment Opportunity Commission?
 yes  no  
Any inquiries from the Fair Labor Standards Enforcement Act?
yes  no  
Any inquiries from the Civil Rights Act of 1991?
 yes  no  
Any inquiries from the U.S. Department of Labor?
 yes  no  
Any inquiries from any state or local government agency?
 yes  no  
Any inquiries from the Age Discrimination Employment Act?
 yes  no  
Any inquiries from the Americans with Disabilities Act?
 yes  no  
Do you have Federal contracts or serve as a subcontractor on contracts over $50,000 per year?
 yes  no  
Has there been a Company merger within the last 24 months?
 yes  no  
Is a Company merger expected within the next 24 months?
 yes  no  
Do you anticipate layoffs within the next 24 months?
 yes  no  
Do you use an employment application for all applicants for hire?
 yes  no  
Do you have an affirmative action plan?
 yes  no  
Has your affirmative action plan been updated within the last 12 months?
 yes  no  
Do you have a written policy regarding harassment?
 yes  no  
Do you have a written pay raise program for your company?
 yes  no  
Do you have an established internal dispute resolution or grievance process?
 yes  no  
Do you have a written disciplinary process?
 yes  no  
Do you have a performance appraisal process?
 yes  no  
Do you evaluate all employees annually?
 yes  no  
Are employee terminations reviewed by Human Resources?
 yes  no  
Are employee terminations reviewed by legal counsel?
 yes  no  
Do you have written policies for Americans with Disabilities Act? 

yes  no   

LOSS INFORMATION

Describe any Losses-Claims in the last 5 years related to allegations of wrongful termination, discrimination or sexual harassment:

 

COVERAGE INFORMATION
Liability Limits Requested:

Deductible Requested:
Current Insurance Company:
Current Annual Premium:
Misc Information to help the agent:
Please press the Submit Button ONCE.
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Thank you for your interest.




17821 E 17th St, Suite 100, Tustin, CA 92780 :: LICENSE #0543173