Employment Practices Quote

Company Information
Name of Prospective Insured *
Mailing Address
Nature of Business
Number of Years in Business
Annual Revinues
Number of Employees:
Total
Full Time
Part Time
Seasonal
Temporary
Independant Contractors
Union
1) Does the applicant have an HR or use HR Management Service?
Yes  No
2) Does the applicant use an employment application?
Yes  No
3) Does the applicant provide all employees with a written employee performance evaluation?
Yes  No
4) Does the applicant have a written job descriptions?
Yes  No
5) Does the applicant publish an employee handbook and distribute to all employees?
Yes  No
IF YES- An at-will statement? Yes  No
IF YES- Signed acknoledgment by the employee? Yes  No
IF YES- An Anti-harassment policy and procedure? Yes  No
IF YES- A written employee grievance policy and procedure? Yes  No
6) Does the applicant Have an anti-discrimination policy and procedure or an EEOC statement?
Yes  No
7) Does the applicant require all terminations be reviewed by HR/legal council or upper management?
Yes  No
8) Current Employment Practices Liability Insurance
If yes, provide the following:
Expiration Date
Carrier
Premium
Limit
Deductable
Retro Date (If Applicable)
9) Average turnover rate for the past 3 years:
10) Does the applicant anticipate any mergers, acquisitions, or layoffs in the next 12 months?
Yes  No
Has the applicant been involved in any claims or lawsuits, including the EEOC in the past 5 years
involving employment related claims, such as wrogful termination, discrimination, or harassment?
Yes  No
IF YES- Please provide details including the nature of the allegations, current status of the claim, and any legal expenses incurred or paid and any settlement paid by either the applicant or the insurance company.
* = Required Field
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