Insurance EPL Form

Insurance EPL Form

Applicant / Insured Information

Corporation    LLC    Partnership    Sole Proprietorship    Nonprofit

Policy Details

Policy Type:

Policy Period From: To:

Retroactive Date (if applicable):

Coverage Options

Select requested coverages (check all that apply):

Wrongful Termination    Discrimination    Sexual Harassment    Retaliation

Failure to Promote    Third-Party Harassment    Wage & Hour Liability (subject to underwriting review)    Defense Outside the Limit

Exclusions and Limitations (Acknowledgement)

The following exclusions and limitations commonly apply to EPL policies. Applicant must acknowledge by checking the items that are understood and accepted. Failure to acknowledge will not bind the insurer but may affect underwriting.

Intentional Acts and Dishonest Acts Exclusion    Prior Acts / Known Circumstances Exclusion    Bodily Injury / Property Damage Exclusion   

Wage & Hour or Fair Labor Standards Act Exclusion    Punitive and Exemplary Damages (as allowed by law)    Contractual Liability Exclusion

Claims History

Has the applicant, any predecessor entity, or any current or former director, officer or employment manager been involved in any employment-related claim, suit, demand, or administrative proceeding in the last 5 years?    Yes    No

Recent Incidents / Loss Information (If Applicable)

Date of Incident:

Documentation available (check all that apply):

Termination Letters    Internal Investigation Reports    EEO / Charge Filings    Settlement Agreements    Payroll / Timekeeping Records

Beneficiary / Loss Payee Information

Primary Payee Name:

Contingent Payee Name:

Declarations and Certification

The undersigned declares that to the best of their knowledge the statements made in this form are true and complete. The applicant understands that this form is a record relied upon by the insurer in evaluating the risk and issuing the policy. The applicant further certifies that no material facts have been omitted and that any dossiers, reports, or attachments provided are accurate and complete.

The applicant authorizes the insurer and its representatives to make any investigation and inquiry in connection with this application, including verification of employment practices loss history and review of relevant corporate records, personnel files, and investigation reports. This authorization shall be effective as to all persons and entities who may possess information relevant to underwriting or claim matters.

The applicant understands and agrees that coverage will not be bound until a policy is issued and premium is paid as required. Any material misrepresentation, omission, or fraudulent statement on this form may render the policy voidable in accordance with the policy terms and applicable law.

Agent / Broker Information (if applicable)

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