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EPL Application Questions

Location Address

Multi-line address
Is your mailing address different from your location address?
Yes
No
Do you have any of the following (Check all that apply)
Do more than 50% of all employees currently earn more than $100,000?
Yes
No
Is the applicant a subsidiary of another organization?
Yes
No
Is the applicant a franchisee of another organization?
Yes
No
Does the applicant want any subsidiary(s) covered?
Yes
No
Does each entity proposed for insurance have a written e-mail/internet policy in place or willing to implement one?
Yes
No
Does each entity have a written anti-discrimination and anti-harassment policy in place?
Yes
No
Has any entity closed, sold, merged-with, or acquired a company in the past 12 months or anticipates doing so in the next 12 months?
Yes
No
Has any entity downsized, laid off, or reduced staff in the past 12 months or anticipates doing so in the next 12 months?
Yes
No
Has any employment related, third party discrimination, or harassment inquiry, complaint, notice of hearing, claim, or suit been made against the applicant or its directors, officers, members, or employees?
Yes
No
Is any person aware of facts/circumstances/situations that may result in such claims?
Yes
No
Has any policy for Employment Practices Liability Insurance ever been cancelled or non-renewed by a carrier?
Yes
No
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