Employment Practices Liability Application Download the WBPI Employment Practices Liability Application Form or fill in the form below. If you are a human and are seeing this field, please leave it blank. Fields marked with an * are required Section 1. General Information Name of Applicant Business Entity Name Mailing Address City State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip / Post Code HR Contact Name Phone Fax Email Number of Office Employees Applicant is CorporationPartnershipLLCIndividualOther 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. YesNo 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 Retention (Deductible) Options $5,000$10,000$25,000Other 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 YesNo 2. A written policy and procedure on anti-discrimination or an EEOC statement prohibiting discrimination YesNo 3. Utilize an employment application that contains an at-will provision YesNo 4. Scheduled Management and Supervisory workplace training on HR related issues, including but not limited to anti-harassment and anti-discrimination and conflict resolution YesNo 5. Open door policy and internal complain written procedure YesNo 6. An orientation program for all employees communicating work place procedures YesNo 7. Termination review by management, HR manager, or outside professional or law firm YesNo 8. Does your organization anticipate any of the following in the next 12 months? 8a. Selling or closing any locations or operations? YesNo If YES, how many? 8b. Acquiring or opening any new locations or operations? YesNo 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? YesNo 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? YesNo 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? YesNo 4. If No, do you anticipate that your facilities will be in compliance with ADA Law within the next 12 months? YesNo 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? YesNo Employment Practices Liability Insurance Location and Employee Information Schedule
Download the WBPI Employment Practices Liability Application Form or fill in the form below. If you are a human and are seeing this field, please leave it blank. Fields marked with an * are required Section 1. General Information Name of Applicant Business Entity Name Mailing Address City State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip / Post Code HR Contact Name Phone Fax Email Number of Office Employees Applicant is CorporationPartnershipLLCIndividualOther 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. YesNo 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 Retention (Deductible) Options $5,000$10,000$25,000Other 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 YesNo 2. A written policy and procedure on anti-discrimination or an EEOC statement prohibiting discrimination YesNo 3. Utilize an employment application that contains an at-will provision YesNo 4. Scheduled Management and Supervisory workplace training on HR related issues, including but not limited to anti-harassment and anti-discrimination and conflict resolution YesNo 5. Open door policy and internal complain written procedure YesNo 6. An orientation program for all employees communicating work place procedures YesNo 7. Termination review by management, HR manager, or outside professional or law firm YesNo 8. Does your organization anticipate any of the following in the next 12 months? 8a. Selling or closing any locations or operations? YesNo If YES, how many? 8b. Acquiring or opening any new locations or operations? YesNo 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? YesNo 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? YesNo 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? YesNo 4. If No, do you anticipate that your facilities will be in compliance with ADA Law within the next 12 months? YesNo 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? YesNo Employment Practices Liability Insurance Location and Employee Information Schedule