Employment Practices Liability Insurance Application (EPLI)

Employment Practices Liability Insurance (EPLI) protects businesses against employee-related lawsuits involving allegations of wrongful termination, discrimination, harassment, retaliation, and other employment-related claims. Coverage can help pay for legal defense costs, settlements, and judgments, subject to policy terms and exclusions. Even if an employer has done nothing wrong, defending against an employee lawsuit can be extremely costly, making EPLI an important coverage for businesses of all sizes.

I. INSTANT QUOTE INFORMATION

Primary Applicant’s name

Location address

City

State

Zip code

Web address

Email address of primary contact

Description of Operations

Full-time employees

Part-time employees

Temporary/Seasonal employees

Independent contractors

Leased employees

Employees located in California

Employees located in Florida

Employees located in Louisiana

Employees located outside the U.S.

II. UNDERWRITING INFORMATION

1. Year established

2. Do more than 50% of all employees currently earn more than $100,000?

• Yes
• No

3a. Is the applicant a subsidiary of another organization?

• Yes
• No

3b. Is the applicant a franchisee of another organization?

• Yes
• No

3c. Name of parent and/or franchisor and location

4. Does the applicant want any subsidiary(ies)/affiliate(s) covered?

• Yes
• No

4a. Name of subsidiary(ies)/affiliate(s)

4b. Is the subsidiary(ies)/affiliate(s) at least 50% owned by the applicant?

• Yes
• No

4c. Does the subsidiary(ies)/affiliate(s) fall within the same class of business as the applicant?

• Yes
• No

5a. Expiring policy – Retroactive date

5b. Expiring policy – Carrier

5c. Expiring policy – Limits

5d. Expiring policy – Retention

5e. Expiring policy – Premium

6a. Has any entity proposed for insurance closed, sold, merged with or acquired any company in the past 12 months or anticipates doing so in the next 12 months?

• Yes
• No

6b. Has any entity proposed for insurance downsized, laid off or reduced staff in the past 12 months or anticipates doing so in the next 12 months?

• Yes
• No

6b. If Yes, what percentage of the workforce was/will be affected? (%)

7. Within the last five years, has any employment related, third party discrimination, or third party harassment inquiry, complaint, notice of hearing, claim or suit been made against any entity proposed for insurance or any person proposed for insurance in the capacity of director, officer, LLC member, or employee?

• Yes
• No

8. Is any person proposed for insurance aware of any fact, circumstance, or situation which may result in an employment related, third party discrimination, or third party harassment claim against an entity proposed for insurance or its directors, officers, LLC members, or employees?

• Yes
• No

9. Has any policy for employment practices liability insurance ever been cancelled or non-renewed by the carrier? (Do not answer if applicant is located in Missouri)

• Yes
• No

III. WRITTEN EMPLOYMENT GUIDELINES

Written email/internet policy

• Applicant currently has a written email/internet policy in place
• Applicant agrees to implement a written email/internet policy within 60 days of the effective date of coverage
• Applicant does not have a written email/internet policy in place and will not implement such policy

Written anti-discrimination policy

• Applicant currently has a written anti-discrimination policy in place
• Applicant agrees to implement a written anti-discrimination policy within 60 days of the effective date of coverage
• Applicant does not have a written anti-discrimination policy in place and will not implement such policy

Written anti-harassment policy

• Applicant currently has a written anti-harassment policy in place
• Applicant agrees to implement a written anti-harassment policy within 60 days of the effective date of coverage
• Applicant does not have a written anti-harassment policy in place and will not implement such policy

IV. ADDITIONAL APPLICANT INFORMATION

Applicant’s mailing address

Mailing city

Mailing state

Primary suit employee?

Mailing zip code

Submit