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This is an application for a claims made policy

General Information
A Name of Firm:
  Address:
  City: State: Zip:
  Firm Telephone No:   Fax No:
 
B Contact Person Date Practice Established?  
  Contact Telephone No:   Fax No:
  Email Address:
  Check here to join the AICPA Insurance Programs e-mail list to receive Risk Management Alerts and product information. Please be sure to include your e-mail address above.
 
C Total Owner and Employee Compensation (All Locations): for 12 months ended
 
D List all locations or branch offices by city and state (include approximate number of employees at each location).
Branch City State
 
E Has the firm ever purchased Employment Practices Liability (EPL) Insurance before, whether stand alone or attached to other coverages? Yes No
 
Years Renewal Date Carrier Limit Deductible Premium
 
F Has your EPL Insurance ever been cancelled or non-renewed other than for non-payment of premium? If Yes, please provide details. (IF) This question is not applicable to Missouri residents. Yes No

 

Employee/Equity Interest
A Current number of employees and equity owners:
  Full-time Part-time Temporary/Agency
  Seasonal* * Average number of months engaged
 
B List number of full-time employees and equity owners whose total compensation including commissions/bonus and any other compensation falls within these ranges:
 
$75,000 to $149,000 $150,000 to $249,999 $250,000 and over
 
C How many members of the firm are equity owners?
 
D What is the average annual percentage turnover of full-time employees over the past year? (terminated both voluntarily and involuntarily) during the year divided by (at beginning of year plus hired during the year)
 
E Has the firm had any branch or office closings, consolidations, work force reduction or layoffs affecting 20% or more of the total number of employees within the past 12 months? Yes No
 
F In the case of downsizing, would the firm consult employment law counsel prior to terminating any employee? Yes No

 

Training of Managers/Supervisors

 
A Has the firm's managers and/or supervisors attended any training programs on employer-employee relations in the past year? Yes No
     
B Did the program include Sexual Harassment Training? Yes No
     
C Was training on Sexual Harassment extended to all employees? Yes No

HR Policies and Procedures
A Does the firm have a Human Resources or Personnel Dept. Manager? Yes No
  If No, who handles this function? Name Title
 
B Does the firm require job applicants to complete an employment application? If Yes, please attach a copy Yes No
  Does it contain "at-will" termination wording? Yes No
C Does the firm perform any of the following pre-employment screenings? (Check if yes)
  Check employment history Check references
  Post-offer drug/alcohol testing:  Check credit
  third party Check credentials/licensing
  in-house Check for criminal record
D Does the firm publish an employee handbook? Yes No
  1. Is it distributed to all employees? Yes No
  2. Do employees sign acknowledging that they received it? Yes No
  3. Date current handbook was last reviewed/updated:
  4. Date of next review/update:
  5. Is this review/update done by legal counsel experienced in employment law? Yes No
  6. If not, who does the review/update?
 
E If your firm publishes an employee handbook, does it contain policies on the following:
  1. Sexual Harassment? Yes No ...      If yes, is it distributed annually to all employees? Yes No
  2. Equal Employment Opportunity? Yes No ...      If yes, does it list protected classes? Yes No
  If yes, does it use omnibus wording: "including all classes protected by federal, state or local law"? Yes No
  3. The Americans with Disabilities Act? Yes No
  4. Open Door for complaints? Yes No
  5. "At-will" wording? Yes No
  6. Family & Medical Leave Act? Yes No
  7. Separate Pregnancy Leave? Yes No
  8. Substance Abuse? Yes No
 
F Does the firm provide regular, written performance evaluations for most employees? Yes No
 
G Does the firm have written job descriptions for most jobs? Yes No
 
H Does the firm provide employees with a "hotline" phone number in order to register complaints?
If Yes, please attach information regarding the "hotline".		 Yes No
I Who of the following must review terminations prior to any action being taken? Check all that apply:
  1.) Managing Partner or Officer check if applicable
  2.) HR Manager or person in charge of HR check if applicable
  3.) Outside legal counsel experienced in employment law check if applicable
  4.) Other, explain?
J Does the firm regularly consult with legal counsel who specializes in employment law to discuss employee-employer relation issues?...... Yes No
If Yes to I(3) or J, who is this employment law counsel?
  Name Firm
  City Phone No.

Loss/Claim History
A In the past five years has the firm had any wrongful termination, discrimination or harassment (sexual or non-sexual) claims or demands (whether insured or not and whether or not any loss has been paid) including any EEOC or similar state administrative filings or charges made against the firm?
(This should include third party claims made by non-employees)............... Yes No
    
1 If the firm's response to questions A. is "Yes", please indicate the total number of claims and/or demands in the past five years:
A Supplemental Claim Form must be completed for each claim or demand. The number of Supplemental claim forms attached must match the total number of claims and/or incidents indicated in question A.1.
   
B Is any Management or Supervisory Employee* aware of any fact, incident, or circumstance which may result in a claim being made against the firm? For example, but not by way of limitation, we consider it reasonable for you to foresee that a claim may be brought against the firm if a person:
  • Makes a formal complaint to a supervisory employee of discrimination, harassment or unfair employment practices;
  • Threatens to hire an attorney;
  • Complains of discrimination, harassment or unfair treatment;
  • Frequently complains of discrimination, harassment or unfair treatment;
  • Complains of a failure to accommodate under The Americans With Disabilities Act (ADA).

If any management or supervisory employee is aware of any fact, incident or circumstance as described above please answer "Yes" here................. Yes No


Coverage Selection

 Indicate below your desired coverage options:
A $100,000 (5 or less employees) $250,000 $500,000
$1,000,000 $2,000,000 Other
 
B $2,500 (5 or less employees) $5,000 $10,000
$15,000 $25,000 $50,000 Other
C Claim Expenses: Claim expenses reduce limits of liability Claim expenses in addition to limits of liability
D Desired Effective Date:

WARNING - ALASKA, ARIZONA, COLORADO, FLORIDA, GEORGIA, HAWAII, KENTUCKY, NORTH CAROLINA, NEW JERSEY, NEW YORK, MAINE, OHIO, OREGON, OKLAHOMA, PENNSYLVANIA, AND VIRGINIA RESIDENTS ONLY

Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime. For New York residents only: and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. For Alaska, Arizona, Florida, Georgia, North Carolina, and Oregon residents only: All statements and descriptions in this application for insurance and in any negotiations therefore, by or on behalf of the insured, shall be deemed to be representations and not warranties. For Colorado residents only: Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies. For Hawaii residents only: For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or benefit is a crime punishable by fines or imprisonment, or both.

The Application Firm warrants on its behalf and on behalf of all Management and Supervisory Employees* that after full investigation and inquiry the statements set forth herein are true and include all material information.

The Applicant Firm further warrants on its behalf and on behalf of all Management and Supervisory Employees* that if the information supplied on this application changes between the date of this application and the inception date of the policy, it will immediately notify CPA EmployerGard through the producing broker of such change. The submission of this application does not bind Virginia Surety Company, Inc. to offer nor the Applicant firm to accept insurance, but it is agreed that this application (facsimile or copy of original) shall be the basis of the insurance and will be attached to and made a part of the policy should a policy be issued. If a facsimile or copy is submitted for attachment to the policy, then the Applicant Firm warrants that the facsimile or copy is a true and current duplicate of the original. It is also acknowledged that the information in this application has been verified by the individual in charge of Human Resources.

*Management or Supervisory Employee means, owner of a sole proprietorship, directors, members of the Board of Managers or management committee members, managing partner of the firm, in-house counsel, risk manager, or any person performing the human resource management function.