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Employment Practices Liability


Person To Contact

Company Name *
Company Owner *
Street *
City *
State / Province *
ZIP / Postal Code *
Primary Phone Number *
E-Mail Address *
First Name *
Last Name *
Total # of Employees *
# of Full Time Employees *
# of Part-Time Employees *
Any Change In # of Employees Last 12 Months *
Any Anticipated Change in # of Employees Next 12 Months *
How Many Locations do you have *
Have You Been In Business Longer than 3 Years *

Do Over 50% of Employees Earn over $ 75,000 *

Any Locations in Louisana or outside us ? *

Do You Currently Have Employment Practices Liability Policy *

Current Insurance Provider
Current Policy End Date
/ /
Within the last 5 years has any employment related, or third party discrimination, or third party harassment inquiry, complaint , notice of hearing, claim or suit been made against the applicant *

Does Applicant have any email or internet policy currently in force ? *

Does Applicant have an Anti-Discrimination policy currently in force ? *

Any person aware of any fact, circumstances or situation which may result in any employment claim *

Submission Validation
Required

Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

Per the terms of our online privacy policy we will not resell your information to any third-party.

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