EPLI EZ APP

EZ APP allows us to begin a discussion of your client’s needs. In most cases, we are able to give you a quick indication of the likely premium. No coverage is in force unless and until A&M delivers a binder or policy to you or your client.

Employment Practices Liability EZ App

1. Applicant Name: 2. Address: Website: 3. Type of Business: Number of Locations: 4. Number of Full-time Employees: 5. Number of Part-time Employees

6. 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

If Yes, what percentage of the workforce was/will be affected?

7. Does the Applicant publish and distribute an employment handbook? Yes No

8. Loss history (5 years) for all wrongful termination, discrimination and sexual harassment claims: Yes No

9. Prior Employment Practices Insurance? Yes No

If yes, please provide details:

Carrier: Limits: Deductible: Premium: Effective Date:

Retrodate:

10. Coverage desired:

Limits Deductible Effective Date

11. Other Material Information: Agency Name: Agent/broker: Agency Address: Phone Number: Fax Number: E-mail Address: Agency Website: