Employment Practices Liability Insurance (EPLI) Quote Request

Please take a moment to fill out the form below and one of our representatives will contact you with a free, no-obligation quote. This information will be kept confidential and will be used for quote purposes only.

* Required fields.

General Information
Your Full Name: *
Your Company:
Address:
City:
State:     Zip:
Business Phone: *   Fax:
E-mail Address: *

Employee Information
No. of F-T Employees:
No. of P-T Employees:  
No. of Employees
within Salary Range:
$1-30,000   $30,001-50,000  
$50,001-100,000   > $100,000  

Prior/Pending Claims
Within the past 5 years, has any administrative hearing / claim been made or is now pending against the organization?

Yes   No

Is any person aware of any fact or circumstance that may 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 anticipated to be any reduction in staff in the past / future 12 months? If YES, explain:
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 in place currently?
If YES:		 a) Inception date of first policy:
b) Current Carrier:

Describe Any Claims You've Had in the Past 3 Years

Additional Comments or Questions

Please click the "Submit Quote Request" button to send your quote request. No coverage is in effect until bound by an insurance carrier. This is a request for quotation only.