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Name of Firm
Address
City
State
Zip
Date Practice Established
Firm Telephone Number
Fax Number
Contact Person
Contact Telephone Number
Contact Fax Number
Contact E-mail Address
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List all locations or branch offices by city and state (inclosing approximate number of employees at each location).

Has the firm ever purchase Employment Practices Liability (EPL) Insurance before, whether stand alone or attached to other coverages? .......... Yes No

Has your EPL Insurance ever been cancelled or non-renewed other than for non-payment of premiums? .......... Yes No
If Yes, please provide details. This question is not applicable to Missouri residents.
 
Employees/Equity Interest
Current number of employees and equity owners
Full-time

Part-time
Temp/Agency
Seasonal*
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 $149,999
$150,000 to $249,999
$250,000 and over
How many members of the firm are equity owners
What is the average annual percentage turnover of full-time employees over the past year?
[(Number terminated both voluntarily and involuntary) during the year divided by (number at beginning of year plus number hired during the year)]
Has the firm had any branch or office closings, consolidation, work force reduction or layoffs affecting 20% or more of the total number of employees within the past 12 months? ..........
Yes No
In the case of downsizing, would the firm consult employment law counsel prior to terminating any employee? .......... Yes No
 
Training of Managers/Supervisors
Has the firm's managers and/or supervisors attended any training programs on employer-employee relations in the past year? .......... Yes No
Did the program include Sexual Harassment Training? .......... Yes No
Was training on Sexual Harassment extended to all employees? .......... Yes No
 
HR Policies and Procedures
Does the firm have a Human Resources or Personnel Dept. Manager? .......... Yes No
If No, who handles this function?
Name
Title
Does the firm require job applicants to complete an employment application? ..........
Yes No
Does it contain "at-will" termination wording? .......... Yes No
Does the firm perform any of the following pre-employment screenings? (Check if yes)
Check employment history Check references Check credit Post-offer drug/alcohol testing ( In-house Third Party ) Check credentials/licensing
Check for criminal record
Does the firm publish an employee handbook? .......... Yes No
If yes, answer the following:
Is it distributed to all employees? .......... Yes No      
Do employees sign acknowledging that they received it? .......... Yes No     
Date current handbook was last reviewed/updated:    
Date of next review/update:           
Is this review/update done by legal counsel experienced in employment law? ..........
Yes No
If not, who does the review/update:    
If your firm publishes an employee handbook, does it contain policies on the following:
Sexual Harassment? .......... Yes No      
If Yes, is it distributed annually to all employees? .......... Yes No
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
The Americans with Disabilities Act? .......... Yes No
Open Door for complaints? .......... Yes No      
"At-will' wording? .......... Yes No      
"Family & Medical Leave Act? .......... Yes No
Separate Pregnancy Leave? .......... Yes No      
Substance Abuse? .......... Yes No
Does the firm provide regulate, written performance evaluations for most employees? ..........
Yes No
Does the firm provide employees with a "hotline" phone number in order to register complaints? .......... Yes No
Who of the following must review terminations prior to any action being taken? (Check if yes)
Managing Partner or Officer HR Manager or person in charge of HR Outside Legal Counsel experienced in employment law
Other, explain?    
Does the firm regularly consult with legal counsel who specializes in employment law to discuss employee-employer relation issues? .......... Yes No
Name   Firm
City   Phone no.
 
Loss Claim History
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 any loss has been paid) including any EEOC or similar state administrative filings or charges made against the firm? (This should include any third party claims made by non-employees) .......... Yes No
If the firm's response to the previous question 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 this form.
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 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;
  • Asks for a severance package in excess of what is being offered;
  • Complains of discrimination, harassment or unfair treatment and threatens to do something about it;
  • 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 circumstances as described above please answer "Yes" here and disclose the facts, incidents or circumstances on a separate form. This should include third party potential claims by non-employees. Anything that is disclosed or should have been excluded from coverage:  ..................... Yes No
 
Coverage Selection

Indicate below your desired coverage options:
Limits of Liability:     $100,000 (5 or less) $250,000 $500,000 $1,000,000 $2,000,000 Other
Per Claim Deductible:
$2,500 (5 or less) $5,000 $10,000 $15,000 $25,000 $50,000
Other
Claim Expenses:
Claim expenses reduce limits of liability   Claim expenses in addition to limits of liability
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 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 Applicant 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 this 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. Signing of this application does not bind Virginia Surety Company, Inc. to offer nor the Application Firm to accept insurance, but it is agreed that 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 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.
Agent Name     Agent License Number