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Asia Insurance Business Employment Practices Quote

Customer Information
Business Name
First Name	Middle Initial	Last Name
Street #	Street Name	Apt or Unit
City	State	Zip	-
Home Phone	Work Phone	Email

Current number of Employees, including owners, partners, officers and directors for the Headquarter state
	Full-Time	Part-Time	Temporary	Seasonal
Non-Union
Union
Total number of persons employed by the applicant in each of the last 3 years (all locations)
Year		Number of Employees
Year		Number of Employees
Year		Number of Employees
Total Number of employees that were terminated by the business and the total number of employees that voluntarily left their employment in the past three years (all locations)
Year		Terminated and Voluntarily Left
Year		Terminated and Voluntarily Left
Year		Terminated and Voluntarily Left
If applicable, list all additional locations by city and state and indicate the number of employees at each location.
Have any EEOC complaints, NLRB charges or lawsuits been made against you by current or former employees within the past five years?			Yes No
If yes, please describe
Year	Description			Total Amount of Loss



Is the applicant aware of any facts, incidents or circumstances which may result in any Employment Practices Liability losses, claims or suits being made against them?			Yes No
If yes, please provide details
Are any plant, facility, branch or office closings or layoffs anticipated within the next 24 months?			Yes No
If yes, please provide details

Desired Limits: (Each Wrongful Employment Act / Aggregate) (other limits may be available upon request)
$100,000/$100,000	$250,000/$250,000	$500,000/$500,000	$750,000/$750,000
$1,000,000/$1,000,000	$2,000,000/$2,000,000
Desired Deductible: (Each Wrongful Employment Act)
$2,500	$5,000	$7,500	$10,000
$15,000	$20,000	$25,000

Is your business currently covered by an Employment Practices Liability policy?			Yes No
Are the following published and distributed to all employees
a) Employee Manual?			Yes No
b) Sexual Harassment Statement?			Yes No
c) Equal Employment and Discrimination Statement?			Yes No
d) Employee Grievance Procedures?			Yes No
e) Discipline Procedures?			Yes No
Is there an employment application used for all applicants?			Yes No
Are annual written performance evaluations conducted for all employees?			Yes No
Please indicate whether the following optional coverages are desired:
a) Coverage for Wrongful Acts that take place outside of the United States of America, it’s territories and possessions, Puerto Rico, or Canada; and Coverage for claims made against you by leased workers and independent contractors?			Yes No
If yes, what percent of your workforce is comprised of leased workers	%	If yes, what percent of your workforce is comprised of independent contractors	%
b) Coverage for Punitive Damages; and Increased limits for earnings lost from $100 to $1,000 per day?			Yes No

Please use the space below to add comments regarding any special circumstances or coverage needs

Disclosure

Where permitted by law, the insurance companies we quote will individually confirm your information through consumer reports, which may include credit reports. Each company will provide the source of the report if you are interested. Your information may be shared with the quoting company's affiliated underwriting companies, independent representatives or other insurance partners.

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