Insurance EPLI Update Form

INSURANCE EPLI UPDATE FORM

Use this form to request a change or to update exposure information for Employment Practices Liability Insurance (EPLI) currently in force. Completion and signature by an authorized representative is required for consideration. Submission does not, by itself, bind coverage; any change becomes effective only upon issuance of an endorsement by the insurer.

INSURED INFORMATION

POLICY DETAILS

REQUESTED UPDATE(S)

Check all requested changes and provide supporting detail where indicated.

EMPLOYMENT EXPOSURE

Please provide current employment totals and payroll information.

HR PRACTICES & RISK MITIGATION

Indicate which of the following are currently in place. If checked, provide dates where requested.

Written employee handbook

Regular harassment/discrimination training

Formal HR disciplinary and termination procedures

Pre-employment background checks

Written employment agreements for key employees

CLAIMS & INCIDENT HISTORY

Disclose all claims, notices, charges or suits involving employment practices in the past five (5) years. Failure to disclose known claims or incidents may render coverage null and void for related matters.

No claims, charges, notices or suits in the past five (5) years

ATTACHMENTS CHECKLIST

Please indicate which documents accompany this update request. Submission of requested documents may be required prior to endorsement.

Employee handbook

HR policies / disciplinary procedures

Training records (dates, attendee lists)

Claims ledger / loss run

Other (describe)

EXCLUSIONS & LIMITATIONS (SUMMARY)

The policy contains exclusions and limitations. Typical exclusions applicable to EPLI include, but are not limited to: (a) bodily injury or property damage claims; (b) criminal acts committed by an insured; (c) claims for intentional or fraudulent acts where the insured’s conduct is judicially determined to be intentional; (d) ERISA, workers' compensation, unemployment or similar statutory benefit claims; (e) claims arising from pollution or environmental matters; and (f) contractual liability beyond insured obligations. The insurer’s policy language controls.

BENEFICIARY / PAYEE INFORMATION

For payment of claim proceeds or premium refunds, provide payee information if different from the named insured.

DECLARATION AND AUTHORIZATION

The undersigned authorized representative of the named insured declares that the statements contained herein and in any attachments are true and complete to the best of their knowledge and belief. The undersigned acknowledges that the insurer will rely on this information in determining whether the requested change will be endorsed to the policy. The insured agrees to notify the insurer in writing of any material change in the information supplied. The undersigned further acknowledges that any material misrepresentation, omission, or concealment of fact may result in denial of coverage or rescission of all or part of the policy as permitted by law and the policy terms.

By signing below, the authorized representative certifies that they are lawfully authorized to execute this update request on behalf of the named insured and that any attachments provided are true copies of corporate records or other original documents.

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