Employment Practices Liability Insurance Update

EMPLOYMENT PRACTICES LIABILITY INSURANCE UPDATE

Effective Date of this Update:

Employer / Organization Information

Corporation    Limited Liability Company (LLC)    Partnership    Sole Proprietorship    Other:

Primary HR Contact — Personal and Position Information

Title:    Department:

Reporting Manager:

Phone:    Email:

Position Information (Contact)

Employment History (Most Recent — 1)

Dates Employed:

Employment History (Previous — 2)

Dates Employed:

Education

References (Professional)

Phone:    Email:

Phone:    Email:

Phone:    Email:

Policy Information

Policy Effective Date:    Policy Limits:

Retroactive Date (if applicable):

Total Number of Employees:    Number of Part-time / Contractors:

Material Changes to Operations, Structure, or Ownership

Pursuant to the terms of the policy, the undersigned must report any material change in operations, ownership, or structure that could reasonably give rise to an employment-related claim. Indicate below whether any such change has occurred since the last notice to the insurer.

Merger or Acquisition    Bankruptcy or Insolvency Filing    Sale of Substantially All Assets    New Subsidiary Formed

Workforce Actions and Labor Relations

Have there been any of the following actions since the policy inception or since the last update? Check all that apply and provide details.

Layoffs or Reductions in Force    Furloughs    Union Organizing or Collective Bargaining Activity    Reclassification of Employees / Contractors

Yes    No

HR Policies, Practices, and Risk Management

Have the following policies or programs been implemented, materially revised, or rescinded since the last reporting period? Check applicable items and provide dates and details.

Employee Handbook Issued or Revised    Anti-Harassment / Discrimination Policy    Mandatory Arbitration or Class/Collective Action Waiver    Background Check / Screening Policy

Yes    No

Claims, Charges, and Litigation History

Since the inception of the policy (or since the last update), have any employment-related claims, suits, charges, notices, or demands been made against the organization or any of its past or present employees, directors, or officers?

Yes    No

Regulatory or Administrative Proceedings

Are there any pending or threatened governmental, regulatory, or administrative investigations or proceedings involving employment practices (including wage & hour, discrimination, labor relations, or benefits compliance)?

Yes    No

Representations, Authorization, and Certification

The undersigned authorized representative of the organization declares that to the best of their knowledge the information provided on this Employment Practices Liability Insurance Update is true, complete and presented in good faith. The undersigned understands and acknowledges that this information may be relied upon by the insurer in determining coverage, premium, or underwriting decisions. The undersigned further agrees to promptly notify the insurer of any material change in fact, circumstance, or condition which arises between the date of this Update and the effective date of any renewal or endorsement.

By signing below, the undersigned authorizes the insurer and its authorized representatives to verify any of the information provided in this Update, to contact listed references and prior employers, and to obtain background, employment and litigation history information regarding the organization and the primary contact as permitted by law.

I consent to verification and background checks as described above

I certify that all information provided in this Update (and any attachments) is true, accurate and complete to the best of my knowledge. I understand that misrepresentation or omission of material facts may be grounds for denial of coverage or rescission of the policy. I further certify that I am authorized to provide this information on behalf of the organization and that I will provide prompt written notice of any subsequent material change.

At-Will & Equal Employment Disclosures

At-Will Employment: Unless otherwise specified in a written agreement signed by an authorized representative of the organization, employment relationships remain at-will and may be terminated by either the employee or the organization at any time, with or without cause or notice.

Equal Employment Opportunity: The organization affirms that it maintains an equal employment opportunity policy and does not discriminate on the basis of race, color, religion, sex, national origin, age, disability, genetic information, or any other status protected by law.

Attachments and Additional Information

Acknowledgment and Signature

The undersigned certifies under penalty of perjury that they are an authorized representative of the organization and that the information contained herein is true and correct. The undersigned acknowledges the continuing duty to report material changes as required by the policy terms.

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