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Desired Limits: Desired Deductible:
Name of Company
Contact Person: Title:
Phone Number: Fax:
Street Address:
City/State/Zip: email:
Nature of Business:
How long has the company been in business?       How long under current management?
Total number of employees: Full Time     Part Time
(including Partners, Directors and Officers, at all locations)
What is your average annual turnover rate? %
No. of separations during the year x 100 =  %
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Total no. of employees
Do you currently have active EPLI coverage? yes  no
If yes, what carrier?   What are the limits/deductible/copay?
Do you have a Human Resources or Personnel Department? yes   no
Do you require job applicants to use an employment application?  yes  no
Do you take steps to establish an at-will employment relationship with:
Employees? yes  no Partners? yes  no Officers? yes  no
Please indicate whether or not you publish and/or implement the following:
yes no yes no
Employment Handbook Written grievance/complaint procedures
Anti-sexual harassment policy Open door policy/procedures
Anti-discrimination policy Dept. of Labor FMLA notifications for leave
Equal opportunity statements "Not an employment contract" language
Do you have a method and practice of updating your policies/procedures to meet client changes in the legal climate and distributing it on an annual basis?  yes  no
If no, are you willing to do so? yes  no
Do you obtain signed employee acknowledgements? (If yes, please indicate below) yes  no
Employee Handbook   signed acknowledgments of individual policies and procedures
Do you require terminations to be reviewed by a central source?  yes   no
If yes, by whom?
If no, are you willing to do so? yes  no
Do you require managers/supervisors to attend training, educational programs/seminars or staff meetings covering employer/employee relations within a 12 month period?  yes  no
If no, are you willing to do so?  yes  no
Are you aware of any facts, incidents or circumstances which may result in claims
being made against you?  yes  no
If yes, how many, and explain the circumstances.
Have you had any cases of inappropriate employment acts, discrimination, wrongful termination and sexual harassment in the last 5 years?  yes   no
If yes, how many, and explain the circumstances.
Do you wish to request coverage for Third Party Exposure?  yes  no
   

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