Are electronic signatures valid for EPLI applications?

Yes. Electronic signatures meet legal standards under the ESIGN Act (15 U.S.C. ch. 96) and UETA in most states, provided intent, consent, signer attribution, and record retention are satisfied.

What attachments do insurers require?

Typical attachments include loss runs for five to seven years, employee handbooks, and management-level statements. Insurers may also request audited payroll or organizational charts.

Who is authorized to sign the application?

An authorized officer or person with delegated authority should sign. Confirm signer authority per corporate bylaws or board resolution to avoid validity challenges.

Can I correct an application after submission?

Corrections require a formal amendment or resubmission. Notify the broker or insurer immediately and provide a signed errata or revised application to prevent coverage disputes.

Is notarization or witness required?

Most EPLI applications do not require notarization, but certain attestations or state-specific forms might. Check insurer requirements and state law prior to signing.

What if signers cannot access the online platform?

Provide an alternate signing method such as in-person signing or a downloadable PDF for wet signature, then upload the executed document and preserve the chain of custody.

Electronic Signature
Templates
Insurance
Insurance EPLI Applications

Insurance EPLI Applications

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

EMPLOYMENT PRACTICES LIABILITY INSURANCE (EPLI) APPLICATION

Applicant / Insured Information

Insured Legal Name DBA / Trade Name (if applicable) Principal Business Address

Primary Contact Name:

Primary Contact Title:

Primary Contact Phone:

Primary Contact Email:

Date of Organization / Incorporation Entity Type (check all that apply)

Corporation LLC Partnership Sole Proprietor Nonprofit Other:

Business / Operational Details

Primary Business Description (principal activities)

Number of Employees (U.S.):

Number of Employees (Worldwide):

Independent Contractors:

Annual Payroll (most recent fiscal year)

Officer Payroll:

Clerical Payroll:

Policy Details Requested

Requested Coverage Limit Retention / Deductible Annual Premium Indication

Policy Period From:

To:

Requested Retroactive Date:

Coverage Options (select all to be included)

Wrongful Termination Employment Discrimination (race, sex, age, etc.) Sexual Harassment Retaliation Claims Wage and Hour / Overtime Claims Invasion of Privacy / Defamation Breach of Employment Contract Prejudgment Interest (where insurable) Punitive or Exemplary Damages (considered where insurable)

Prior Claims / Loss Experience (last 5 years)

Provide details for each employment-related claim, charge or suit. If none, state "None".

Claim 1 - Date of Loss Claim 1 - Description

Amount Paid / Reserved:

Current Status:

Claim 2 - Date of Loss Claim 2 - Description

Amount Paid / Reserved:

Current Status:

Claim 3 - Date of Loss Claim 3 - Description

Amount Paid / Reserved:

Current Status:

Risk Management & Employment Practices

Answer the following to allow evaluation of controls and procedures. Attach supporting documentation where requested.

Do you maintain a written employee handbook? Yes No

Anti-Harassment / Anti-Discrimination Policy Policy in writing and distributed to employees Policy actively enforced Policy under periodic review

Employee Training

Frequency of employment-related training:

Use of Written Employment Agreements or Arbitration Agreements Yes No Pre-Employment Screening Background checks conducted Reference checks conducted Documentation Checklist (attach with submission) Employee handbook attached HR policies attached Payroll records attached Prior claim reports attached

Exclusions & Notices

The proposed policy will contain standard exclusions including, but not limited to: intentional acts, fraud or dishonesty determined by final adjudication, bodily injury or property damage, ERISA claims, and any claims arising from collective bargaining or union activity unless specifically endorsed. The insurer reserves the right to apply additional exclusions based upon underwriting review of submitted materials.

Acknowledgement of Standard Exclusions I acknowledge I have read and understand the typical exclusions set forth above and agree that additional exclusions may be applied upon underwriting.

Beneficiary / Claim Payee Information

Designate the individual or entity to whom claim payments or return premiums should be addressed if other than the insured.

Payee Name Relationship to Insured Percentage (if multiple payees)

Declarations, Authorizations and Warranty

By signing below, the applicant certifies that the statements and particulars contained in this application are true, complete and correctly recorded to the best of the applicant's knowledge. The applicant understands and agrees that this application forms the basis of the contract of insurance. Any material misrepresentation, omission or concealment of fact may be grounds for denial of coverage or rescission of the policy. The applicant authorizes the insurer to make any inquiries deemed necessary to evaluate the application and loss-control measures, including, where permitted by law, obtaining records and claim history from prior insurers and regulatory authorities.

The applicant further warrants that all claims, suits, demands or administrative proceedings known to the applicant have been disclosed in this application. Notice to any representative of the insurer or to any agent does not constitute notice to the insurer unless submitted in writing to the insurer's underwriting department and acknowledged in writing.

Additional Remarks or Material Facts (if any)

Applicant Printed Name:

By (Authorized Signature):

Date:

Title / Capacity of Signatory:

Capacity Represented (if signing on behalf of the insured):

What Insurance EPLI Applications Are and how they’re used

An Insurance EPLI Application is the formal form submitted to underwriters when a business requests Employment Practices Liability Insurance (EPLI). The application documents company identity, business operations, employee counts, payroll, HR policies, past employment-related claims or lawsuits, and risk-management programs. Insurers use this information to underwrite coverage, set premiums, and define exclusions or retroactive dates. Applications frequently require supporting schedules, board resolutions, loss runs, and signed attestations from authorized officers before a policy can be bound.

Why complete an accurate EPLI application

A complete, accurate application speeds underwriting, reduces the chance of coverage disputes, and produces more reliable premium estimates while documenting representations for the insurer.

Who typically completes or receives EPLI applications

External counsel or third-party administrators may review or sign sections depending on the insurer’s requirements and the applicant’s governance.

HR leaders and in-house counsel who provide employment-policy and claims details to underwriters.
Insurance brokers or agents who collect information, prepare submissions, and negotiate terms.
Risk managers or CFOs who review payroll, employee counts, and loss-run attachments prior to signature.

Essential sections included in most EPLI applications

Standard EPLI applications organize underwriting data into consistent sections so underwriters can assess exposure quickly and fairly.

Applicant Details

Legal entity name, FEIN, address, contact person, corporate structure, and state(s) of operation required to identify applicant and legal jurisdiction.

Business Operations

Description of core activities, number of locations, NAICS/SIC code, and revenue ranges to classify industry risk and exposure.

Employment Practices

Policies for hiring, discipline, termination, anti-harassment, and employee handbook status that illustrate HR controls and training programs.

Claims History

Prior employment-related claims, suits, settlements, and open matters including dates and amounts; often requires loss runs for the last five to seven years.

Risk Management

Internal practices such as training, investigations, third-party audits, and use of employment counsel that mitigate liability exposure.

Attachments & Declarations

Signed statements, board resolutions, prior-policy copies, and supporting schedules that validate representations on the application.

Key data fields the application will request

FEIN / TIN: Federal employer identifier

Legal Name: Exact corporate or LLC name

Employee Count: Total full- and part-time

Payroll Total: Annual wages reported

Loss Runs: Claims summary years

HR Policies: Handbook and procedures

Step-by-step: completing an EPLI application

Follow these core steps to prepare a clean, insurer-ready submission and avoid delays during underwriting.

01

Gather documents: Collect loss runs, employee counts, payroll, and policy copies.
02

Answer sections: Complete applicant, operations, claims, and HR sections truthfully.
03

Attach schedules: Upload loss runs, handbook excerpts, and board approvals.
04

Review and sign: Confirm answers, sign, date, and deliver to broker or insurer.

Configuring online completion and routing for EPLI submissions

Set up an electronic workflow that enforces required fields, collects attachments, and routes the signed application to stakeholders.

Field	Configuration
Authentication	Email link or SMS code; increase strength for executive signers
Routing	Sequential routing: preparer → broker → authorized officer
Attachments	Require PDF loss runs and handbook excerpt uploads
Notifications	Auto-notify broker and compliance when signed

Digital signature and file compatibility considerations

Use a platform that preserves an audit trail, stores signed copies in the required format, and supports HIPAA or BAA where health data appears.

Integrations: Salesforce | NetSuite | Google Workspace
File Formats: PDF, DOCX, XLSX accepted
Auth Options: Email link, SMS, KBA

Typical eSubmission path for an EPLI application

A clear electronic path reduces turnaround time: prepare, validate, sign, and transmit to the insurer or broker with tracking.

Upload application: Prepare a PDF or DOCX version of the completed form.
Place fields: Add signature, date, and attachment fields for required documents.
Send to signers: Route to preparer, broker, and authorized officer in order.
Transmit to insurer: Submit signed package to insurer or upload to their portal.

Key timing expectations and common deadlines

Timelines vary by insurer and broker; confirm required submission windows and renewal dates to avoid coverage gaps.

Application submission window:

Submit at least 30–60 days before desired policy effective date for full underwriting.

Renewal notice deadline:

Provide updated application or disclosures as required prior to renewal date.

Claims disclosure timing:

Disclose prior claims as requested; late disclosure may be treated as misrepresentation.

Underwriting response time:

Insurer may take 1–4 weeks for review depending on complexity.

Policy effective date processing:

Binders or endorsements usually issued within 48–72 hours of final approval.

Common preparation mistakes to avoid

Incomplete loss runs or summary entries that lack dates and disposition details, prompting insurer follow-up and delay.
Mismatched legal names or FEINs between application and supporting documents, causing underwriting to request clarifications.
Vague policy language or generic HR statements without evidence of enforcement or training programs leads to higher premiums.
Uploading unreadable scans or splitting required exhibits across multiple documents rather than attaching a single, labeled PDF.

Consequences of inaccurate or incomplete applications

Misrepresentation: Can void coverage

Late disclosure: May lead to denial of claims

Incorrect FEIN: Causes payment and tax issues

Missing signatures: Application may be invalid

Incomplete loss runs: Triggers premium adjustments

Noncompliant storage: Regulatory exposure possible

How organizations use electronic EPLI applications

Real-world examples illustrate how digital completion speeds binding and preserves an audit trail for later review.

Tech Data (Bob Dutkowsky)

Tech Data streamlined submissions with an online signing workflow that centralized documents and approvals.

The broker bundled loss runs and HR policies for faster review.
As a result, the company shortened underwriting cycles and improved internal coordination while preserving a secure audit trail for renewals.

Fertility Centers of Illinois (John Butler)

The organization moved to electronic applications to support remote signers and maintain compliance.

Signatures were captured with audit logs and attachments.
This reduced back-and-forth with carriers and ensured that signed packages were reproducible for audits and claims defense.

eSignature vendor pricing and feature comparison for completing EPLI applications

Platform choice affects authentication, audit trails, and bulk submission capabilities. The table compares starting price and major features relevant to EPLI workflows.

	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 vendor	Varies by vendor	Varies by vendor	Varies by vendor
Bulk Send	Yes	Yes	Yes	Yes	No
Audit Trail	Yes	Yes	Yes	Yes	Yes
HIPAA Compliant	Yes	Yes	Yes	No	No

Frequently asked questions about Insurance EPLI Applications

Practical answers to common issues that arise when preparing, signing, and submitting EPLI applications electronically.

Need help? Contact support

Are electronic signatures valid for EPLI applications?
Yes. Electronic signatures meet legal standards under the ESIGN Act (15 U.S.C. ch. 96) and UETA in most states, provided intent, consent, signer attribution, and record retention are satisfied.
What attachments do insurers require?
Typical attachments include loss runs for five to seven years, employee handbooks, and management-level statements. Insurers may also request audited payroll or organizational charts.
Who is authorized to sign the application?
An authorized officer or person with delegated authority should sign. Confirm signer authority per corporate bylaws or board resolution to avoid validity challenges.
Can I correct an application after submission?
Corrections require a formal amendment or resubmission. Notify the broker or insurer immediately and provide a signed errata or revised application to prevent coverage disputes.
Is notarization or witness required?
Most EPLI applications do not require notarization, but certain attestations or state-specific forms might. Check insurer requirements and state law prior to signing.
What if signers cannot access the online platform?
Provide an alternate signing method such as in-person signing or a downloadable PDF for wet signature, then upload the executed document and preserve the chain of custody.

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