Can an EPLI application be signed electronically?

Yes. Electronic signatures are legally valid under the federal ESIGN Act (15 U.S.C. §7001) and state UETA statutes where adopted, provided the signature shows intent, consent, attribution, and reliable record retention.

What supporting documents should accompany the application?

Attach loss runs, employee handbooks, disciplinary records, payroll summaries, and training materials. Loss runs covering five to seven years are commonly required to verify claims history and underwriting calculations.

Who is authorized to sign the application?

The signer should be an officer or authorized agent with authority to bind the organization. Brokers may attest or submit on behalf of applicants if carrier procedures allow broker attestations.

Are notarization or witnesses required for EPLI forms?

Generally not for insurance applications, but some carriers or states may require notarized attestations or RON for certain affidavits. Confirm requirements with the carrier and refer to state notary rules.

How do I correct errors after submission?

Notify the broker or insurer immediately. Carriers typically require an amended application or written addendum; material corrections may affect underwriting decisions and coverage terms.

Is an electronic signature enforceable in court?

Yes, electronic signatures are enforceable under ESIGN (15 U.S.C. §7001) and UETA when requirements are met. Exceptions exist for certain types of documents listed in the statutes; verify applicability before relying on an e-signature.

Electronic Signature
Templates
Insurance
EPLI Insurance Application Form

EPLI Insurance Application Form

This template is fully customizable. Edit the text, fill out the fields, and send it for signature. Give it a try!

EPLI INSURANCE APPLICATION FORM

Applicant / Insured Information

Applicant Name Doing Business As (DBA) Entity Type (check all that apply)

Corporation LLC Partnership Sole Proprietor Non-profit

Federal Tax ID (EIN) / SSN Primary Contact / HR Representative Address

Telephone:

Email:

Website:

State of Formation:

Date of Formation:

Number of Employees (full-time equivalent):

Annual Payroll (USD):

Named Insured(s) (if different from Applicant)

Policy Details Requested

Requested Effective Date:

Policy Period From:

Policy Period To:

Coverage Limit Desired Retention / Deductible Estimated Annual Premium

Coverage Options (select all that apply)

Wrongful Termination / Constructive Discharge
Discrimination (race, color, religion, sex, national origin, age, disability, etc.)
Sexual Harassment
Retaliation Claims
Wage & Hour Claims (FLSA) — coverage subject to underwriting approval
Defamation/Libel/Slander arising from employment matters
Breach of Employment Contract / Implied Contract Claims

Loss History / Prior Acts

In the past five (5) years, has the Applicant or any proposed insured had any employment-related claim, suit, demand or administrative charge filed against it or any of its directors, officers or employees? Yes No

If Yes, provide details for each matter (date of loss, claimant, allegation, disposition, amounts paid/reserved)

Risk Management Practices

Does the Applicant have a written employee handbook, employment policies, or anti-harassment policy? Yes No

If Yes, date last updated

Does the Applicant use written employment agreements or arbitration agreements? Yes No

Describe any reduction in workforce, significant restructuring, or ongoing labor disputes

Exclusions, Limitations and Acknowledgments

The Applicant acknowledges that coverage, if issued, will be subject to standard policy exclusions including, but not limited to: intentional or criminal acts by the insured, bodily injury or property damage, punitive or exemplary damages to the extent uninsurable by law, claims arising from the Applicant's failure to carry statutorily required insurance (including workers' compensation), claims known to the Applicant prior to the effective date, and any express exclusions negotiated in the policy. The Applicant further acknowledges that wage and hour exposures and certain statutory remedies may be excluded or limited unless specifically endorsed.

Applicant acknowledges and agrees to promptly notify the insurer of any claim, circumstance or notice which may give rise to a claim. Failure to provide timely notice may affect coverage.

Beneficiary / Premium Refund Payee

If a premium refund or return premium becomes payable under the policy, please designate the party to whom such funds should be paid.

Beneficiary / Payee Name

Relationship to Applicant:

Percentage Payable:

Documentation Checklist (attach with application)

Employee handbook / policies
Prior loss runs for the past five years
Sample employment or arbitration agreements
Organizational chart and list of officers / directors
Most recent financial statements (if requested)

Declaration and Authorization

The Applicant declares that the statements and particulars contained in this application and any attachments are true, correct and complete. The Applicant understands that the information provided is material to the acceptance of the risk and the terms of any policy issued. The Applicant warrants that no fact material to the underwriting of the risk has been withheld.

The Applicant authorizes any person or organization to release to the insurer or its representatives any records or information requested in the course of underwriting and claim investigation, including prior claim history and employment-related records. This authorization shall remain in effect for the duration of the underwriting process and, if a policy is issued, for the policy period and any extended reporting period.

The Applicant understands that completion of this application does not bind coverage. Coverage, if offered, will be evidenced by a policy issued by the insurer and will be subject to the policy terms, conditions, exclusions and endorsements.

Additional Remarks / Special Considerations

Applicant Name (Printed):

By (Authorized Signature):

Title:

Date:

What the EPLI Insurance Application Form Is

The EPLI Insurance Application Form is the standardized questionnaire employers complete to request Employment Practices Liability Insurance coverage. It captures corporate identity, payroll and workforce metrics, employment-practices policies, and a detailed claims and litigation history used by underwriters to assess exposure to wrongful termination, discrimination, harassment, or retaliation claims. Responses determine premium, policy limits, exclusions, and underwriting conditions. Brokers commonly attach loss runs, employee handbooks, and risk-mitigation documentation. When filed electronically, the form must meet ESIGN and applicable state electronic-record rules to preserve signature intent, attribution, and reproducibility.

Why a Complete, Accurate Application Matters

A properly completed EPLI Insurance Application Form streamlines underwriting, improves risk assessment accuracy, and documents representations that affect coverage. Accurate submissions reduce processing delays, support binding decisions, and preserve an audit trail useful for claims handling and regulatory review.

Who Typically Completes and Uses the EPLI Application

Typical signers and users include employers, insurance brokers, risk managers, and underwriting teams responsible for evaluating employment-practices exposure.

Employers and HR leaders — provide company data, workforce metrics, and policy summaries to underwriters.
Insurance brokers and agents — complete application sections, submit attachments, and liaise with carriers during underwriting.
Risk managers and legal counsel — confirm disclosures, review claims history, and document mitigation measures.

Assign responsibility clearly: correct signer selection and timely, accurate input reduce underwriting friction and strengthen the organization’s coverage position.

Essential Sections Found on a Professional EPLI Application

Core sections of a professional EPLI Insurance Application Form clarify organizational facts, policy history, and risk controls so underwriters can evaluate exposures and issue binding terms.

Applicant Info

Provide the legal entity name, DBA, FEIN, primary business address, NAICS code, years in operation, and senior contact for jurisdictional identification and underwriting.

Payroll & Workforce

Report total payroll, employees by category, seasonal staffing patterns, independent contractor usage, and executive counts that materially affect exposure and premium calculations.

Claims History

List all employment-practices claims, suits, settlements, reserves, and open matters for the prior five to seven years and attach loss runs with disposition dates.

Policies & Procedures

Attach employee handbooks, anti-harassment policies, investigation procedures, and training records to evidence risk-mitigation practices and potential underwriting credits.

Management Practices

Describe hiring, termination, performance review, background-check, accommodation, and disciplinary procedures used by the organization that influence insurer assessment.

Attestation & Signature

An authorized signatory must attest to accuracy, sign and date, and include title and authority; note any state-specific notarization or broker attestations required.

Step-by-Step: Complete and Submit an EPLI Application

Follow these steps to complete and submit an EPLI Insurance Application Form accurately through an online workflow.

01

Gather Documents: Collect FEIN, payroll reports, current loss runs, handbooks, and HR policies before you start.
02

Complete Sections: Answer all questions fully; avoid placeholders like 'see attached' without attaching the referenced document.
03

Attach Evidence: Upload loss runs, disciplinary logs, and training records as searchable PDFs for underwriting review.
04

Sign & Submit: Signer confirms attestations, signs electronically, and sends the completed form to broker or carrier as required.

How to Configure an Online EPLI Application Workflow

Configure an online form workflow to enforce completeness, strong authentication, and automated delivery to carrier and broker recipients.

Field name or UI label (header)	Configuration
Require signer authentication (SMS or email)	Enable SMS code or email link authentication for signers.
Conditional section visibility for claims details	Show claims fields only when prior-claims answers are selected.
Require file attachment: loss runs and handbooks	Accept PDF and DOCX; set file-size and required attachments.
Automated reminders, expiry and routing	Send reminders at intervals and auto-route completed files to recipients.

Where to Send or File Completed Applications

Completed EPLI applications are routed to the underwriting channels specified by the carrier or broker; choose the correct destination based on the carrier’s submission instructions.

Submit to Carrier: Upload to insurer underwriting portal or email the assigned underwriter per carrier instructions.
Deliver to Broker: Send signed application and attachments to your broker for review and submission.
Upload to Agency Portal: Use broker/agency document management portals when required for centralized recordkeeping.
Retain Copies: Keep a signed copy for employer records and claims defense documentation.

Technical and Compliance Considerations for eSubmission

Use a compliant eSignature platform supporting PDF and DOCX uploads, audit trails, and secure storage for completed EPLI applications.

Integrations: Salesforce, NetSuite, Google Workspace, and document storage integrations.
Supported Formats: PDF and DOCX accepted; searchable PDFs recommended.
Authentication Options: Email/SMS codes, two-factor, or advanced signer verification.

Security and Compliance Snapshot for Digital Applications

Encryption: TLS 1.2/1.3 in transit; AES-256 at rest

Certifications: SOC 2 Type II, ISO 27001, PCI DSS

Audit Trail: Detailed timestamps, IP addresses, action history

HIPAA BAA: Business Associate Agreement available on request

Authentication: Email, SMS, or advanced two-factor options

Data Retention: Configurable retention and tamper-evident storage

Typical Timelines and Deadlines for Processing

Timelines for underwriting and policy placement vary by carrier and application complexity; plan ahead to avoid coverage gaps during review.

Underwriting turnaround:

Typically 7–14 business days for standard reviews.

Binding request deadline:

Carrier may require a binder within 24–72 hours of acceptance.

Premium effective date:

Start date is set in the application or binder; confirm before coverage begins.

Extensions and supplements:

Provide requested documents promptly to avoid rescission or coverage delay.

Policy issuance:

Final policy typically issued after full underwriting, often within 2–4 weeks.

Common Mistakes That Slow or Jeopardize Underwriting

Incomplete claims disclosure — failing to list paid or pending employment claims leads insurers to rescind coverage or deny claims during review; always attach complete loss runs.
Incorrect or inconsistent FEIN or legal name can delay verification, cause premium misassignment, and require amended application forms or supplemental affidavits.
Missing authorizations or unsigned attestations — unsigned sections or unverified signer authority frequently cause binding delays or additional notarization requests.
Unreadable or incomplete attachments — scanned images or truncated loss runs increase underwriting friction and often trigger re-submission requests.

Risks and Consequences of Inaccurate Applications

Coverage Denial: Misstatements may cause denial

Rescission Risk: Policy voided for material misrepresentations

Premium Adjustment: Underwriting changes can raise premium

Claims Exclusion: Specific allegations excluded from coverage

Regulatory Penalty: Violations may trigger fines or sanctions

Delayed Protection: Coverage gap during underwriting

eSignature Vendor Comparison for Processing EPLI Applications

A neutral feature and pricing snapshot for common eSignature providers used to sign and route EPLI Insurance Application Forms; signNow appears first per page conventions.

	signNow	DocuSign	Adobe Sign	PandaDoc	HelloSign
Starting Price	$8/user/mo	$15/user/mo	$14/user/mo	$19/user/mo	$15/user/mo
Free Trial	7-day free trial	Varies	Varies	Varies	Varies
Bulk Send	Yes	Yes	Yes	Yes	No
Audit Trail	Yes	Yes	Yes	Yes	Yes
HIPAA Compliant	Yes	Yes	Yes	No	No
Envelope Cap	No cap	100 envelopes/user/year	Varies by plan	Varies by plan	Varies by plan

Frequently Asked Questions About EPLI Application Completion

Answers to common questions about legality, signatures, supporting documents, and corrections for EPLI Insurance Application Forms.

Need help? Contact support

Can an EPLI application be signed electronically?
Yes. Electronic signatures are legally valid under the federal ESIGN Act (15 U.S.C. §7001) and state UETA statutes where adopted, provided the signature shows intent, consent, attribution, and reliable record retention.
What supporting documents should accompany the application?
Attach loss runs, employee handbooks, disciplinary records, payroll summaries, and training materials. Loss runs covering five to seven years are commonly required to verify claims history and underwriting calculations.
Who is authorized to sign the application?
The signer should be an officer or authorized agent with authority to bind the organization. Brokers may attest or submit on behalf of applicants if carrier procedures allow broker attestations.
Are notarization or witnesses required for EPLI forms?
Generally not for insurance applications, but some carriers or states may require notarized attestations or RON for certain affidavits. Confirm requirements with the carrier and refer to state notary rules.
How do I correct errors after submission?
Notify the broker or insurer immediately. Carriers typically require an amended application or written addendum; material corrections may affect underwriting decisions and coverage terms.
Is an electronic signature enforceable in court?
Yes, electronic signatures are enforceable under ESIGN (15 U.S.C. §7001) and UETA when requirements are met. Exceptions exist for certain types of documents listed in the statutes; verify applicability before relying on an e-signature.

be ready to get more

Join over 28 million airSlate SignNow users

Sign Now