Employment Practices Liability (EPL)Insurance Application Company Name * Website * http:// Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Primary Contact * First Name Last Name Email * HR Contact * First Name Last Name Email * How many full-time employees do you have? * How many part-time? * How many contractors or seasonal? * How many employees or contractors are in California? * Have there been any leadership changes in last 3 years (other than retirement/death)? * Yes No In the past 12 months, any closures/mergers/consolidations causing 20%+ layoffs (or planned)? * Yes No Public offerings or private placements in last 24 months (or planned)? * Yes No Reorganization/arrangement with creditors in last 24 months (or planned)? * Yes No Mergers, acquisitions, or divestitures in last 24 months (or planned)? * Yes No Does the company maintain an employee handbook with formal policies addressing employment-at-will? * Yes No Discrimination? * Yes No Workplace harassment (including sexual harassment)? * Yes No Equal employment opportunity? * Yes No Disability accommodations and reasonable adjustments? * Yes No Have all officers and management staff completed sexual harassment prevention training within the last 18 months? * Yes No In the past 3 years, has the company been a party to an employment-related lawsuit, EEOC, NLRB, or similar administrative proceeding? * Yes No Become aware of any facts, allegations, or circumstances that could reasonably result in such a claim? * Yes No Do you have existing Directors & Officers (D&O) coverage? * Yes No Do you have existing Employment Practices Liability (EPL) coverage? * Yes No Do you have existing Fiduciary Liability coverage? * Yes No Do you have existing Cyber Liability coverage? * Yes No Do you have existing Tech Errors & Omissions (E&O) coverage? * Yes No Total Revenue (most recent FY end) * $ Total Assets (most recent FY end) * $ Total Liabilities (most recent FY end) * $ Net Income (most recent FY end) * $ Total Cash (most recent FY end) * $ Prior knowledge of any facts/circumstances that could reasonably give rise to a claim? * Yes No What percentage of customer agreements are standard form vs. manuscript? (Best estimate.) * 0-25% 26-50% 51-75% 76-100% Thank you - your application has been submitted. An Execurisk broker will contact you within 24 hours. In the meanwhile, please send your financial documents to docs@execurisk.com.
