Insurance EPLI Proposal

INSURANCE EPLI PROPOSAL

WHEREAS the Applicant desires a proposal for Employment Practices Liability Insurance for exposures arising from acts, errors or omissions in connection with employment-related practices; and

WHEREAS the Insurer/Broker has prepared a proposal based on the representations made by the Applicant and the underwriting information supplied below; and

NOW, THEREFORE, the parties set forth the proposed terms and conditions as follows. This proposal is subject to final underwriting review, policy terms and conditions, and execution of a policy document.

Parties and Proposal Date

Client Name:

Insurer/Broker:

Proposal Date:

Applicant Information

Scope of Coverage / Scope of Work

Scope of Coverage Proposed: Describe the employment practices exposures, third-party liabilities and services to be covered by the proposed policy. Include any special endorsements or exclusions to be considered.

Proposed Limits, Retentions, and Period

Payment Terms

Premium Amount:   Currency:

Annual    Quarterly    Monthly    Other:

Payment Due Days from Invoice:   Late Fee / Interest Rate:

Underwriting Questions (Answer all; attach explanations where indicated)

1. Has the Applicant had any employment-related claim, suit, or demand made in the past five years?

Yes No

2. Has any director, officer or manager been the subject of an employment-related investigation or claim?

Yes No

3. Has the Applicant implemented an employee handbook, anti-harassment policy, and employee grievance procedure?

Yes No

Risk Management and Loss Control

Describe current risk management practices, training programs, HR procedures, and any third-party review or audits.

Attachments

Please indicate which documents accompany this proposal:

Employee Handbook    HR Policies    Claims History    Other (specify):

Representations, Warranties and Conditions

The Applicant represents and warrants that all information supplied in this proposal is true, complete and accurate to the best of its knowledge and that there are no known facts or circumstances which might give rise to a claim other than as disclosed above. The Applicant agrees to promptly notify the Insurer/Broker of any material change in exposure or any new claim or circumstance prior to policy inception.

Confidentiality

All non-public information exchanged between the parties in connection with this proposal shall be kept confidential and shall not be disclosed to third parties except as required by law, regulatory authority, or to the Insurer's authorized representatives and reinsurers. This confidentiality obligation survives termination or declination of coverage.

Term and Termination

Proposed Policy Start Date:    Proposed Policy End Date:

Either party may terminate coverage in accordance with policy provisions. For installment payment arrangements, failure to pay premium when due may result in cancellation in accordance with the payment terms set above. Notice for non-renewal or cancellation will be provided in accordance with policy language and applicable law.

Governing Law; Entire Agreement

Governing Law: This proposal and any resulting policy shall be governed by and construed in accordance with the laws of the jurisdiction agreed in the policy. Parties consent to the exclusive jurisdiction of competent courts for disputes arising out of this proposal or policy.

Entire Agreement: This proposal, together with any written attachments and the terms of any issued policy, constitutes the entire agreement between the parties with respect to the subject matter herein and supersedes all prior proposals, negotiations and understandings, whether written or oral.

Certifications and Signature

The undersigned certifies that he/she is authorized to sign on behalf of the Applicant and that the information contained in this proposal is true and complete. The Insurer/Broker certifies that this proposal reflects the terms offered pending underwriting and issuance of a policy document.

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