| 1. Name:__________________________________________________ |
| 2. Address:________________________________________________ |
| 3. City/State/Zip:____________________________________________ |
| 4. Phone #: (_____)_______________ 5. Fax #: (_____)________________ |
6. Describe business activities:
__________________________________________________________________ |
| 7. A. Total Number of U.S. employees (excluding owners):________ |
| B. Total number of owners: ________ |
| C. Total number of part-time employees (20 hour per week or less): ________ |
| 9. Do you have a Personnel/Human Resource Department? ___Yes ___No |
| If yes, number of staff: _______ |
| 10. Do you have an employee handbook or manual? ___Yes ___No |
| If yes, has it been reviewed by an attorney? ___Yes ___No |
Is it issued to every employee with written acknowledgment of employee
receipt? ___Yes ___No |
11. Do you use a formal, standardized employment application form?
___Yes ___No |
| If yes, has it been reviewed by an attorney? ___Yes ___No |
| a. Does it contain an "employment at will" statement? ___Yes ___No |
b. Do you require the applicant's signature on the application?
___Yes ___No |
c. Do employment applications include an authorization allowing you to
check references, and if relevant to the position, conviction records?
___Yes ___No |
| 12. Do you conduct periodic audits of personnel policies? ___Yes ___No |
| 13. What was the annual turnover rate for the last three years? |
| (year)____ - _____% (year)____ - _____% (year)_____ - _____% |
| 14. Have you had any claims? ___Yes ___No If yes, attach details. |
| 15. Effective date of previous EPL coverage carried?: ________________ |
| 16. Limits Desired: $500,000 $1,000,000 (circle one) |
17. Deductible Desired: $5,000 $10,000 $15,000 $25,000
$50,000 (circle one) |
EMPLOYMENT PRACTICES LIABILITY QUICK QUOTE FORM