Employment Practice Liability Insurance Quote - ROADMAP INSURANCE SERVICES

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Employment Practice
Liability Insurance Quote

Request an Employment Practice Liability Quote

General Information

Indicates required field

* Indicates required field

Name of Applicant *

First

Last

The legal name of the person who owns the vehicles and will be the primary named person on the insurance policy.

Address *

Line 1

Line 2

City

State

Zip Code

Country

Please enter your mailing address.

Federal Tax ID # *

Nature of Operations *

*Note - Please include description of all Applicants including subsidiaries

Website *

Prior Activities Information

1. Within the last three (3) years, has the Applicant or any person proposed for this insurance in his or her capacity as an employee, officer, or director of the Applicant or another entity been the subject of or involved in any:

a. Litigation, civil, arbitration, administrative or criminal proceeding, civil or criminal charge or hearing, or a written demand seeking monetary or non-monetary damages? *

Yes No

b. Formal or informal investigation, proceeding or inquiry by any federal, state or local govermental agency or regulatory body, including without limitation, the U.S. Department of Justice, the U.S. Department of Labor, or any federal or state office of the Attorney General *

Yes No

2. Within the last three (3) years, has the Applicant had any commercial crime losses? If yes, please provide details on a separate page. *

Yes No

c. Notice of charges or other proceeding from the Equal Employment Opportunity Commission or any similar state or local agency or regulatory body? *

Yes No

If yes, please provide details below *

Employment Practices Coverage Section Information

Is the Applicant seeking Employment Practices coverage? *

Yes No

If yes, please answer the following questions.

1.) Employee and employment compensation information:

Full Time *

Seasonal *

a. Estimated annual remuneration of all employees, including officers, owners, or partners: $ *

Part Time *

Contracted (leased, independent or otherwise) *

b. Number of employees with estimated annual remuneration exceeding $100,000 *

*Note: Remuneration above includes salary, commissions, bonuses and other incentives and does not include any dividends or security based distributions.

2.) Have more than twenty five percent (25%) of the officers or management voluntarily left the employ of the Applicant or had employment with the applicant terminated within the last eighteen (18) months? If yes, please provide details on a separate page. *

Yes No

3.) Does the Applicant anticipate in the next twelve (12) months, or has the Applicant transacted in the last twelve (12) months, any plant, facility, branch or office closing, consolidations or layoffs affecting twenty percent (20%) or more of the employees of the Applicant? If yes, please provide details on a separate page. *

Yes No

4.) Describe the internal controls the Applicant maintains for Employment Practices.

a. Have all management staff and officers attended training and education programs on sexual harassment within the last eighteen (18) months? *

Yes No

b. Does labor relations counsel review the employment policies / procedures at least annually? *

Yes No

c. Is there a separate Human Resources Department? *

Yes No

d. Does the Applicant compensate all interns? *

Yes No

e. Are there written procedures for handling complaints of discrimination or sexual harassment? *

Yes No

f. Are there written procedures for handling employee grievances or complaints? *

Yes No

g. Does the Applicant compensate all interns? *

Yes No

h. Has the Applicant had in place for the past three years or since formation, whichever is the shorter time period, written procedures and guidelines to classify the status of each employee as Non-Exempt or Exempt under the rules and regulations of the Fair Labor Standards Act of 1938, as amended? *

Yes No

Contact Information for EPL risk management services

Name *

First

Last

Email *

Phone Number *

Fax Number *

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Roadmap Insurance Services
109 Muirs Chapel Road
Suite 214
Greensboro, NC 27410
(336) 291-3535
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