Employment Practices Liability Application : Western Bowling Proprietors Insurance

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Fields marked with an * are required

Section 1. General Information

Name of Applicant

Business Entity Name

Mailing Address

City

Zip / Post Code

HR Contact Name

Phone

Fax

Number of Office Employees

Section 2. Location & Employee Information

Total Employees *

Full Time (30hrs/week or more) *

Part Time Employees *

Section 3. Loss History (Both questions 1 and 2 must be answered)

Provide specific claim details for each employment practice claim, lawsuit, or incident

1. Furnish first dollar Loss History (5 years) for all wrongful termination, discrimination, sexual harassment claims, and workplace torts, both state and federal, civil and administrative in the space provided below. Please provide claims details on a separate sheet and attach.

If no claims, check here

Claim Date

Claimant Name

Nature of Claim

Defense Amount

Indemnity Amount

Reserve Amount

Current Status

2. Are you aware of any facts, incidents, or circumstances which may result in a claim against you? If YES, provide details on a separate sheet.

Section 4. Requested Limit Options

Single Limit Options

$250,000
$500,000
$1,000,000

Aggregate Limit Options ($2,000,000 and $3,000,000 aggregate not available with $250,000 single limit option)

$250,000
$500,000
$1,000,000
$2,000,000
$3,000,000

Section 5. Human Resources Procedures

Have you formally adopted and implemented the following:

1. A written policy on anti-harassment and procedures to report harassment to management

2. A written policy and procedure on anti-discrimination or an EEOC statement prohibiting discrimination

3. Utilize an employment application that contains an at-will provision

4. Scheduled Management and Supervisory workplace training on HR related issues, including but not limited to anti-harassment and anti-discrimination and conflict resolution

5. Open door policy and internal complain written procedure

6. An orientation program for all employees communicating work place procedures

7. Termination review by management, HR manager, or outside professional or law firm

8. Does your organization anticipate any of the following in the next 12 months?

8a. Selling or closing any locations or operations?

If YES, how many?

8b. Acquiring or opening any new locations or operations?

If YES, how many?

Section 6. Third Party Discrimination and Sexual Harassment Coverage

1. Do you have written procedures for handling complaints of discrimination and sexual harassment from a person other than an employee?

2. Have you received any complaints alleging discrimination and/or sexual or non- sexual harassment from a person other than an employee in the past 5 years?

If Yes, provide the total number of complaints received. Please provide details on a separate sheet including any amounts paid or reserved.

3. Are your facilities designed to accommodate the disabled in compliance with the Americans with Disabilities Act (ADA) law?

4. If No, do you anticipate that your facilities will be in compliance with ADA Law within the next 12 months?

If No, please explain why.

5. Do you provide training to your employees regarding discrimination and sexual or non-sexual harassment of a person other than an employee?

Employment Practices Liability Insurance

Location and Employee Information Schedule

Employment Practices Liability Application

Download the WBPI Employment Practices Liability Application Form or fill in the form below.