Can I sign the application electronically?

Yes. Electronic signatures are legally enforceable under the ESIGN Act (15 U.S.C. ch. 96) and UETA in most states, provided you follow intent, consent, attribution, and retention requirements.

Do I need a notary for an EPLI application?

Most EPLI applications do not require notarization. Check carrier instructions; if notarization is requested, follow state notary rules or remote online notarization where permitted.

What happens if I discover an error after submission?

Notify your broker or insurer immediately. Corrections may require an amendment, supplemental statement, or re-submission to avoid coverage disputes at claim time.

How long should I retain signed applications?

Retain the signed application for the policy term plus at least three years; longer retention may be required for tax, HIPAA, or state rules.

Is loss run documentation mandatory?

Carriers commonly require five years of loss runs for underwriting. Providing complete loss history reduces follow-up and speeds decision-making.

Can a broker complete and sign on behalf of the employer?

A broker may prepare the application, but the insurer typically requires an authorized company representative’s signature or explicit written authorization to bind coverage.

Electronic Signature
Templates
Insurance
Insurance EPLI Application Form

Insurance EPLI Application Form

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

Insurance EPLI Application Form

Applicant / Insured Information

Applicant Name: DBA / Trade Name (if applicable):

Federal Tax ID / FEIN:

State of Organization:

Date of Incorporation / Formation:

Primary Business Address: Mailing Address (if different):

Primary Contact:

Title:

Telephone:

Email:

Business Operations & Workforce

Primary Industry / SIC Description: Summary of business operations:

Number of Full‑Time Employees:

Number of Part‑Time Employees:

Number of Seasonal / Temporary:

Total Annual Payroll (All Employees):

Coverage Requested

Requested Policy Period From: To:

Limit of Liability Requested:

Retention / Deductible:

Retroactive Date (if applicable):

Coverage Enhancements (check all that apply):

Third‑Party Liability (client/third‑party claims) Punitive / Exemplary Damages (where insurable) Wage & Hour Defense Costs Coverage for Temporary / Contract Workers Defense Costs Outside the Limit

Loss History / Claims

Has the applicant, any predecessor, or any past or present director/officer/partner ever had an employment practices claim, suit, or administrative charge made against them in the last five (5) years? No Yes (if yes, complete below)

If yes, provide claim details (use additional pages if necessary):

Prior Insurance / Underwriting Information

Current EPLI Carrier:

Current Policy Period: From To

Limit / Retention:

Has any insurer ever declined, cancelled, or non‑renewed EPLI coverage for the applicant? No Yes (explain)

Human Resources Practices

Please indicate whether the following policies/practices are currently in place:

Employee Handbook / Written Policies Anti‑Discrimination Policy Anti‑Harassment Policy Employee Training on Harassment/Discrimination Background Checks for New Hires Mandatory Arbitration Agreements

Describe any significant HR practices or exposures not captured above:

Exclusions / Important Notices

The coverage applied for may be subject to standard exclusions including, but not limited to: intentional acts, fraudulent or dishonest acts, bodily injury or property damage, fines or penalties imposed by law, claims arising from criminal acts, and claims covered by workers' compensation. The insurer may also exclude coverage for certain matters where regulatory or statutory law precludes coverage. Any representation in this application that is material and found to be false or intentionally misleading may result in denial of coverage or rescission of the policy.

Beneficiary / Payee for Return Premium (if different)

Beneficiary / Payee Name:

Relationship to Applicant:

Percentage (if applicable):

Declarations and Authorization

The undersigned authorized representative declares that the statements contained in this application and any attachments are true and complete to the best of their knowledge and belief. The applicant understands that this application, and any attachments, becomes part of any policy that may be issued. The applicant agrees to notify the insurer of any material change in the facts contained herein prior to policy issuance or renewal.

The applicant authorizes the insurer to make inquiries and obtain information from any person or organization concerning the accuracy of the statements made and any claim or loss information. The applicant understands that intentional misrepresentation of material fact(s) may be cause for policy rescission or denial of coverage.

I certify that the information provided in this application and any supplemental documents is true, complete, and accurate to the best of my knowledge. I understand that material misrepresentation could void coverage.

Attestation of Accuracy

By signing below, the applicant acknowledges that they have read and understand the representations and warranties contained in this application. The signature below binds the applicant to the statements and authorizations herein.

Printed Name:

Title:

Signature:

Date:

What the Insurance EPLI Application Form Is

The Insurance EPLI Application Form is the document employers complete to request Employment Practices Liability Insurance (EPLI). It collects company identification, operations and payroll data, employee counts, prior claims and loss history, management practices, and requested coverage limits and deductibles. Insurers use it to underwrite exposure to claims such as wrongful termination, discrimination, harassment, and retaliation. Accurate answers affect premium, terms, and the insurer’s offer; incomplete or incorrect responses can delay underwriting or lead to post-claim disputes over coverage.

Why Accurate EPLI Applications Matter

A complete, consistent application speeds underwriting, ensures appropriate coverage limits, and reduces the risk of claim denial or rescission. It provides a documented record insurers rely on to set premiums and exclusions.

Who Typically Completes an EPLI Application

Employers, risk managers, and insurance brokers usually prepare and submit EPLI applications; IT or HR may supply supporting data.

Small business owners and HR managers who assemble payroll and staffing metrics and answer behavioral-policy questions for the insurer.
Risk or compliance officers in mid-market companies who coordinate loss runs, employment policies, and third-party vendor exposures.
Insurance brokers and agents who complete and submit the application on behalf of clients and negotiate policy terms with carriers.

The person submitting should have access to payroll data, prior-claims documentation, and authority to bind or provide accurate company disclosures.

Core Elements of a Professional EPLI Application

A complete application organizes required sections clearly: applicant identity, operations, employment practices, loss history, requested coverage, and authorizing signatures.

Applicant Details

Legal entity name, DBA, FEIN or SSN for sole proprietors, full business address, NAICS or SIC code, and primary contact for policy correspondence and billing.

Requested Coverage

Limits of liability, per-claim and aggregate limits, deductible or retention amounts, desired policy period, and any retroactive date requests or prior acts coverage.

Employment Practices

Policies for hiring, termination, discipline, anti-harassment training, written employee manuals, and whether independent contractors are used regularly.

Claims History

Prior and pending claims, loss runs for the past five years, settlements or judgments, and whether any claim involved punitive damages or regulatory fines.

Risk Controls

HR procedures, employee training programs, background check usage, investigation protocols, and any formal employment-risk mitigation practices.

Declarations

Authorized signature, title, date, and statements certifying accuracy plus insurer-required authorizations to obtain loss history or third-party records.

Step-by-Step: Filling and Submitting an EPLI Application

Follow these steps in order to prepare an accurate submission and reduce underwriting questions.

01

Gather records: Collect payroll, employee counts, and five years of loss runs before you start.
02

Complete sections: Answer each question fully; use attachments for long explanations.
03

Review disclosures: Confirm prior-claim entries, management hires, and policy dates for accuracy.
04

Submit to carrier: Send the completed form and attachments to the insurer or broker using the chosen delivery method.

Digital Workflow Settings for Online Completion

Configure a consistent electronic workflow so the application moves quickly through internal review and insurer submission.

Field	Configuration
Signer order	Primary applicant then broker; set role-based signing order for approvals.
Authentication	Use email plus SMS code for higher assurance during e-signing.
Reminders	Automate 3-day reminder cadence for outstanding signatures or documents.
Storage	Save completed files to an encrypted folder with versioning enabled.

Typical eSubmission Flow

The following concise steps show what happens from upload to final record delivery.

Upload document: Upload the completed application and attach loss runs and supporting PDFs.
Place fields: Add signature, date, and checkbox fields where the carrier requires attestation.
Send to signers: Email secure signing links to authorized signatories and the broker.
Archive copies: Store signed packet and audit trail in your secure records system.

Technical and Format Requirements for eSubmission

Ensure files are PDF or DOCX and that attached loss runs are legible and machine-readable where possible.

File formats: PDF, DOCX, or scanned TIFF accepted by most carriers.
Integrations: Use CRM or document storage connectors to auto-populate fields where available.
Authentication: Email plus SMS or knowledge-based checks strengthen signer identity.

Confirm the carrier’s preferred submission channel and retain the complete audit trail and signed package in encrypted storage for compliance.

Typical Timelines and Processing Expectations

Timing varies by carrier and complexity; use these common timeframes to plan follow-up and premium binding.

Submission to underwriter:

Allow 3–14 business days for initial review depending on carrier workload.

Underwriting questions:

Expect 1–2 rounds of clarifying questions that may add 3–7 days.

Policy issue:

Once approved, policy documents are typically issued within 2–5 business days after payment.

Effective date:

Coverage begins on the agreed effective date once premium is paid and forms are accepted.

Premium adjustments:

Insurers may revise premium after final audit; this can occur 30–90 days after policy start.

Common Mistakes to Avoid

Underreporting employee counts or payroll, which can lead to premium miscalculation and post-claim adjustments.
Omitting prior claims or near-miss incidents; such omissions are material and can void coverage for related claims.
Using inconsistent entity names across attachments, which complicates underwriting and can delay binding.
Failing to attach loss runs or investigative reports; lack of documentation often prompts insurer follow-up and underwriting holds.

Risks and Consequences of Inaccurate Answers

Coverage denial: Insurer may deny claims tied to material misstatements.

Policy rescission: Carrier can rescind the policy for material nondisclosure.

Premium adjustment: Insurer may retroactively increase premium after audit.

Regulatory fines: Improper disclosures can attract state insurance regulator scrutiny.

Contract disputes: Incorrect parties or missing authorizations can invalidate obligations.

Broker liability: Agents may face liability for negligent submission or advice.

Typical eSignature Vendor Pricing and Features

Quick vendor comparison showing starting price, trial availability, bulk-send capability, audit trail presence, and HIPAA support across common providers.

	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 by plan	Varies by plan	Varies by plan	Varies by plan
Bulk Send	Yes (Business Premium)	Yes	Yes	Yes	No
Audit Trail	Yes	Yes	Yes	Yes	Yes
HIPAA Compliant	Yes (BAA available)	Yes	Yes	No	No

Frequently Asked Questions About the EPLI Application

Answers to common questions about completing, signing, and storing an EPLI application to prevent delays and maintain compliance.

Need help? Contact support

Can I sign the application electronically?
Yes. Electronic signatures are legally enforceable under the ESIGN Act (15 U.S.C. ch. 96) and UETA in most states, provided you follow intent, consent, attribution, and retention requirements.
Do I need a notary for an EPLI application?
Most EPLI applications do not require notarization. Check carrier instructions; if notarization is requested, follow state notary rules or remote online notarization where permitted.
What happens if I discover an error after submission?
Notify your broker or insurer immediately. Corrections may require an amendment, supplemental statement, or re-submission to avoid coverage disputes at claim time.
How long should I retain signed applications?
Retain the signed application for the policy term plus at least three years; longer retention may be required for tax, HIPAA, or state rules.
Is loss run documentation mandatory?
Carriers commonly require five years of loss runs for underwriting. Providing complete loss history reduces follow-up and speeds decision-making.
Can a broker complete and sign on behalf of the employer?
A broker may prepare the application, but the insurer typically requires an authorized company representative’s signature or explicit written authorization to bind coverage.

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