Employment Practices Liability (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 Full-Time Employees:

No. of Part-Time 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 note that no coverage is in effect until bound by an insurance carrier. This is a request for quotation only.