Insurance EPLI Application

EMPLOYMENT PRACTICES LIABILITY INSURANCE APPLICATION

Applicant Name:   DBA/Trade Name:

1. APPLICANT / INSURED INFORMATION

2. POLICY DETAILS

Requested Policy Type: Claims-made Occurrence

Policy Period From:   To:   Retroactive Date (if applicable):

Prior Acts Coverage Requested: Yes

3. EMPLOYMENT PRACTICES INFORMATION

Do you maintain written employment policies (harassment, discrimination, termination)?   Yes No

Are employees subject to mandatory arbitration of employment disputes?   Yes No

Do you use employment agreements with confidentiality or non-compete terms?   Yes No

4. CLAIMS / LOSS HISTORY

In the past five (5) years, has any claim, suit, demand or administrative proceeding been made against the applicant or any past or present director, officer or employee?   Yes No

5. COVERAGE OPTIONS & SUBLIMITS

Defense Outside the Limit (DOC): Requested

Third Party Harassment Liability: Requested

6. EXCLUSIONS & ACKNOWLEDGEMENTS

Standard exclusions applicable to this application include but are not limited to claims arising from bodily injury/wrongful termination for non-employment related acts, asbestos, pollution, criminal acts by insured persons, and matters specifically excluded by endorsement. The applicant acknowledges these standard exclusions and understands that additional exclusions may be applied by underwriters.

Applicant Acknowledgement: I acknowledge I have read and understand the exclusions described above and within any policy that may be issued.

7. FRAUD NOTICE, AUTHORIZATION & CERTIFICATION

Fraud Warning: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to criminal and civil penalties in accordance with applicable law.

Authorization: The applicant, on behalf of all persons and entities proposed for coverage, authorizes the release of employment practice, claims, loss, medical and personnel information to the insurer and its representatives for underwriting and claim investigation purposes. The applicant authorizes any past or present employer, insurance carrier, attorney, claims administrator or other person to provide such information. A photocopy of this authorization will be considered as effective and valid as the original.

Certification: I hereby certify that the statements in this application are true and complete to the best of my knowledge. I understand that the insurer may withdraw any quotation or cancel any policy issued if material misrepresentation or omission is subsequently discovered. I further agree to notify the insurer of any material change in the information provided herein prior to policy inception.

8. DESIGNATED PAYEE FOR RETURN PREMIUM (IF APPLICABLE)

9. IMPORTANT NOTICE

The completion of this application does not bind coverage. Coverage will be effective only upon issuance of a policy and payment of the required premium by the applicant, subject to the terms, conditions, limitations and exclusions of the policy. The insurer reserves the right to request additional information or clarification prior to binding coverage.

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