EMPLOYEE PRACTICE LIABILITY
 
 
1. General Information
A. Name:
Address 1:
Address 2:
City: State: Zip:
Phone: Fax:
       
     
B. Describe nature of Business: 
C. When was the company established? SIC Code:
         
   
D. If you are currently insured, please answer the following:
i. Carrier:
ii. Limit:
iii. Deductible:
iv. Premium:
v. Renewal Date:
     
E. Have your managers and/or supervisors attended any training and educational programs or seminars on employer-employee relations in the past year? Yes No
F. Current number of Employees
Full Time:
 Part Time:
 Temp/Agency:
 Temp/Payroll:
               
G. Annual estimate of seasonal work force, if any.
Season workers work months.
H. Number of employees earning over $75,000 annually: 
I. What is the average annual percentage turnover of full time employees over the past year? %
   
 
2. Loss/Claims Information
A. Have you had any losses during the past five years either insured or uninsured? 
If yes, you will have to fill out a Supplemental Claim form for each incident or claim.		 Yes No
B. Are you aware of any facts, incidents or circumstances which may result in claim(s) being made against you? 
If yes, you will have to fill out a Supplemental Claim form for each incident or claim.		 Yes No
       
       
 
3. Human Resources
A. Do you have a Human Resources or Personnel Department/Manager? Yes No
B. Do you require job applicants to use an employee application? Yes No
i. Does it contain at-will wording? Yes No
C. Do you publish an employee handbook? Yes No
If no, skip to section 3D.
i. Do you distribute it to all employees? Yes No
ii. Are all employees required to sign that they received the handbook? Yes No
Does the handbook contain the following policies?
iii. Sexual Harassment? Yes No
iv. Equal Employment Opportunity? Yes No
v. Americans with Disabilities Act? Yes No
vi Open Door/Grievance/Complaint? Yes No
vii. At-Will wording? Yes No
viii. Family & Medical Leave Act? Yes No
ix. Pregnancy Leave (Separate)? (Required in California) Yes No
D. Do you do performance evaluations for all employees? Yes No
E. Do you have written job descriptions for all or most jobs? Yes No
F. Do you require that all terminations be reviewed by:
i. Upper management or owners Yes No
ii. HR department Yes No
iii. In house counsel Yes No
iv. Outside legal counsel specializing in employment law Yes No
G. Does the applicant consult with legal counsel that specializes in employment law to discuss employee-employer relation issues other than termination? Yes No
If yes to section 3F-iv or 3G, who is the employment law counsel?
 
 
Name:
Law Firm:
City:

The above information is given for the purpose of obtaining a non-bindable indication of possible premium.

 
 
 
 
License #: 0578496
Copyright Vicencia & Buckley Insurances Services Inc.
The information herein is for illustration purposes only and is designed as a general description of coverage's. Coverage will be determined by the actual policy language.
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