Insurance EPLI Quote

INSURANCE EPLI QUOTE

Applicant / Insured Information

Requested Policy Terms

Desired Effective Date:

Coverage Options / Endorsements

Select coverages requested (insurer may quote with sublimits or exclusions):
Wrongful termination/discharge
Discrimination (race, gender, age, disability, etc.)
Harassment (sexual harassment and hostile work environment)
Retaliation claims
Third-Party Liability (customers, vendors)
Punitive / exemplary damages (where insurable by law)
Wage & hour / class action coverage (subject to sublimit)

Exclusions / Important Underwriting Notices

The quotation, if issued, will be subject to policy provisions and exclusions. Typical exclusions to be considered include claims arising from: willful or fraudulent acts by the Insured, bodily injury or property damage claims covered by other policies, claims arising from the Insured's insolvency except as specifically provided, and fines or penalties imposed by law where not insurable. The insurer may also exclude known circumstances, pending litigation, or claims that have been previously asserted. The applicant must disclose all known facts or circumstances that may give rise to a claim.

Applicant acknowledges reading and understanding the exclusions summary above.

Claims / Loss History

In the last five (5) years, has the applicant, any predecessor, subsidiary, or past or present executive officer or director been involved in any employment related claim, suit, arbitration, EEOC filing, administrative proceeding, or demand for damages? Yes No

Underwriting Documentation Checklist

Please indicate which documents are provided or will be provided upon request: Employee handbook / HR policies Organizational chart Prior loss runs (minimum 5 years) Employment agreements, arbitration agreements, and policies

Beneficiary / Payee Information

(For payment of return premium or claim proceeds if required by insurer)

Declarations and Applicant Certification

The undersigned authorized representative of the applicant hereby declares that the information provided in this quotation request is true and complete to the best of their knowledge. The applicant acknowledges that any quotation provided is based upon the statements and material facts disclosed herein and that coverage, if bound, will be subject to the terms, conditions, limitations and exclusions of the policy issued. The applicant agrees to notify the insurer of any material change in the facts or circumstances disclosed prior to policy inception. The applicant authorizes the insurer and its representatives to make any investigation and inquiry in connection with this request, including obtaining employment practices loss history and other underwriting information.

The applicant understands that a quotation is not a binder of insurance unless a binding confirmation is issued by the insurer in writing and any premium quoted is an estimate subject to change based upon the insurer's review of final underwriting information and policy terms.

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