Employment Practices Liability
Premium Indication Short Form

General Information
Applicant Name: 
Address: 
City: 
State: 
Zip: 
Phone: 
Date Established: 
Description of Operations:
List any subsidiaries or affiliated companies to be included:
 

Agency Information

Agency Name : 
Address: 
City: 
State: 
Zip: 
Contact Name: 
Phone: 
Email: 
Fax: 
 

Employment Practices Information

Employee Count:
State
# Full-time Employees
# Part-time Employees
 
 
 Check if leased employees are used.
 Check if independent contractors are used.
 Check if the applicant currently has EPL coverage. If yes, fill out below.
Insurer: 
Expiration Date: 
Limits: 
Deductible: 
Retro Date: 
Is Third Party Included?: 
Current Premium: 
 Check if the applicant plans any acquisition, divestiture or closing of   facilities within the next year or has it had any? If yes, please  explain.
 Check if the applicant has a Personnel or Human Resources Dept?
 Check if the applicant has an employee manual which contains a  right to terminate employment at will?
 Check if the applicant is aware of any fact, situation or circumstance which may  result in a claim. If checked, upload or fax details.
 
Indicate any EPL claims and EEOC/State Agency charges over the last five years.:
Date of Occurrence Open / Closed Allegation Damages Paid Damages Reserved Legal Expenses Paid Legal Expanses Reserved
 
Comments:
 
Upload any additional information
File 1    
 

| New | Products | Forms | Library | Internet | Company | Contact | Home |

Copyright © 2006 Cincinnati Intermediaries, LLC. All rights reserved. 
Terms of use and legal disclaimer.
3975 Erie Avenue Cincinnati, Ohio 45208
Voice: (513) 271-3400 Fax: (513) 271-3440
Revised: 25 August 2006