ACORD 827 (2014/12) - Employment Practices Liability Insurance Section

ACORD 827 (2014/12) - Employment Practices Liability Insurance Section
ACORD 827, Employment Practices Liability Insurance Section, is used to apply for employment practices liability insurance coverage.
The form was designed to be used in conjunction with ACORD 825, Professional / Specialty Insurance Application. This form must be attached to
ACORD 825 for a completed application submission.
Form Page 1
Section Name
Field Name
Description
IDENTIFICATION SECTION
Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g., agency or
brokerage).
IDENTIFICATION SECTION
Date
Enter date: The date on which the form is completed. (MM/DD/YYYY)
IDENTIFICATION SECTION
Agency
Enter text: The full name of the producer / agency.
IDENTIFICATION SECTION
Policy Number
Enter identifier: The identifier assigned by the insurer to the policy, or submission, being
referenced exactly as it appears on the policy, including prefix and suffix symbols. If required for
self-insurance, the self-insured license or contract number.
IDENTIFICATION SECTION
Carrier
Enter text: The insurer's full legal company name(s) as found in the file copy of the policy. Use
the actual name of the company within the group to which the policy has been issued. This is
not the insurer's group name or trade name.
IDENTIFICATION SECTION
NAIC Code
Enter code: The identification code assigned to the insurer by the NAIC.
IDENTIFICATION SECTION
Named Insured
Enter text: The named insured(s) as it / they will appear on the policy declarations page.
IDENTIFICATION SECTION
DBA
Enter text: The name by which an organization is doing business.
COVERAGE REQUESTED
Limit Per Claim
Enter limit: The per claim limit for liability coverage.
COVERAGE REQUESTED
Aggregate Limit
Enter limit: The aggregate limit for liability coverage.
COVERAGE REQUESTED
Retention Per Claim
Enter amount: The per claim retention amount for liability coverage.
COVERAGE REQUESTED
Aggregate Retention
Enter amount: The aggregate retention amount for liability coverage.
COVERAGE REQUESTED
Annual Premium
Enter amount: The annual modified premium charged for the EPLI line of business.
COVERAGE REQUESTED
Effective Date
Enter date: The effective date of the policy. The date that the terms and conditions of the policy
commence. (MM/DD/YYYY) As used here, 12:01 AM at the principal address of the applicant.
COVERAGE REQUESTED
Expiration Date
Enter date: The date on which the terms and conditions of the policy will expire. (MM/DD/YYYY)
As used here, 12:01 AM at the principal address of the applicant.
COVERAGE REQUESTED
Separate Defense Costs
Limit Y / N
Enter Y for a Yes response. Input N for No response. Indicates if there is a separate defense
costs limit for the coverage.
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COVERAGE REQUESTED
Separate Defense Costs
Limit Amount
Enter limit: The separate defense costs limit amount.
COVERAGE REQUESTED
Defense Limit - Inside
Check the box (if applicable): Indicates there is an inside defense limit.
COVERAGE REQUESTED
Defense Limit - Outside
Check the box (if applicable): Indicates there is an outside defense limit.
COVERAGE REQUESTED
Pending & Prior Litigation
Date
Enter date: The pending and prior litigation date.
COVERAGE REQUESTED
1. Is the applicant
requesting coverage for
company and directors &
officers?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Is the applicant requesting coverage for company and directors & officers?.
COVERAGE REQUESTED
2. Is the applicant
requesting coverage for
employees?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Is the applicant requesting coverage for employees?.
COVERAGE REQUESTED
Number Of Full Time
Employees
Enter number: The number of full time employees.
COVERAGE REQUESTED
Number Of Part Time
Employees
Enter number: The number of part time employees.
COVERAGE REQUESTED
Number Of Temporary
Workers
Enter number: The number of employees that are temporary workers.
COVERAGE REQUESTED
Number Of Seasonal
Workers
Enter number: The number of seasonal employees.
COVERAGE REQUESTED
3. Is the applicant
requesting coverage for
leased employees?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Is the applicant requesting coverage for leased employees?.
COVERAGE REQUESTED
Total Number of Leased
Employees
Enter number: The number of leased employees.
COVERAGE REQUESTED
4. Is the applicant
requesting coverage for
independent contractors?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Is the applicant requesting coverage for independent contractors?.
COVERAGE REQUESTED
Total Number Of
Independent Contractors
Enter number: The number of independent contractors.
COVERAGE REQUESTED
5. Is the applicant
requesting coverage for
non-profit outside
positions?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Is the applicant requesting coverage for non-profit outside positions?.
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COVERAGE REQUESTED
Total Number Of Volunteers
Enter number: The number of volunteer employees.
COVERAGE REQUESTED
6. Is the applicant
requesting coverage for
punitive damages?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Is the applicant requesting coverage for punitive damages?.
COVERAGE REQUESTED
Punitive Damages Limit
Enter limit: The limit amount for punitive damages coverage.
COVERAGE REQUESTED
7. Is the applicant
requesting coverage for
third party claim?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Is the applicant requesting coverage for third party claim?.
SHARED LIMITS
Shared Limits Y / N
Enter Y for a Yes response. Input N for No response. Indicates if there are shared limits.
SHARED LIMITS
Additional Coverages
Attached Y / N
Enter Y for a Yes response. Input N for No response. Indicates if there are additional
coverages attached.
SHARED LIMITS
D&O Liability
Check the box (if applicable): Indicates the Directors And Officers section is attached to this
application. As used here, check all additional forms that are attached to complete the
submission. If there are any other additional forms attached but not listed, enter the form
number next to the blank check box. Additional ACORD forms, such as state-specific forms,
may also be filled in.
SHARED LIMITS
EPLI
Check the box (if applicable): Indicates the Employment Practices Liability Insurance (EPLI)
section is attached to this application.
SHARED LIMITS
Prof Liability
Check the box (if applicable): Indicates the Professional Liability section is attached to the
application.
SHARED LIMITS
Crime
Check the box (if applicable): Indicates the Crime section is attached to this application.
SHARED LIMITS
Fiduciary
Check the box (if applicable): Indicates the Fiduciary section is attached to the application.
SHARED LIMITS
Other
Check the box (if applicable): Indicates that a section other than those listed is attached to this
application.
SHARED LIMITS
Describe Other
Enter text: The type of section being attached to this application.
EMPLOYEE INFORMATION
In United States
Enter number: The number of employees in the USA. As used here, include employees in
parent company and all subsidiaries.
EMPLOYEE INFORMATION
Outside United States
Enter number: The number of employees outside the USA. As used here, include employees in
parent company and all subsidiaries.
EMPLOYEE INFORMATION
Unionized
Enter number: The number of unionized employees. As used here, include employees in parent
company and all subsidiaries.
EMPLOYEE INFORMATION
Fair Labor Standards Act
Exempt
Enter number: The number of Fair Labor Standards Act exempt employees. As used here,
include employees in parent company and all subsidiaries.
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EMPLOYEE INFORMATION
Fair Labor Standards Act
Non Exempt
Enter number: The number of Fair Labor Standards Act non-exempt employees. As used here,
include employees in parent company and all subsidiaries.
EMPLOYEE INFORMATION
Exempt - Less Than Or
Equal To $50,000
Enter percentage: The percentage of employees with a salary less than or equal to $50,000. As
used here, this is for exempt employees. The salary is including bonuses.
EMPLOYEE INFORMATION
Exempt - Greater Than
$50,000 But Less Than Or
Equal To $100,000
Enter percentage: The percentage of employees with a salary greater than $50,000 but less
than or equal to $100,000. As used here, this is for exempt employees. The salary is including
bonuses.
EMPLOYEE INFORMATION
Exempt - Greater Than
$100,000
Enter percentage: The percentage of employees with a salary over $100,000. As used here,
this is for exempt employees. The salary is including bonuses.
EMPLOYEE INFORMATION
Non Exempt - Less Than Or
Equal To $50,000
Enter percentage: The percentage of employees with a salary less than or equal to $50,000. As
used here, this is for non-exempt employees. The salary is including bonuses.
EMPLOYEE INFORMATION
Non Exempt - Greater Than
$50,000 But Less Than Or
Equal To $100,000
Enter percentage: The percentage of employees with a salary greater than $50,000 but less
than or equal to $100,000. As used here, this is for non-exempt employees. The salary is
including bonuses.
EMPLOYEE INFORMATION
Non Exempt - Greater Than
$100,000
Enter percentage: The percentage of employees with a salary over $100,000. As used here,
this is for non-exempt employees. The salary is including bonuses.
EMPLOYEE INFORMATION
Union - Less Than Or Equal
To $50,000
Enter percentage: The percentage of employees with a salary less than or equal to $50,000. As
used here, this is for union employees. The salary is including bonuses.
EMPLOYEE INFORMATION
Union - Greater Than
$50,000 But Less Than Or
Equal To $100,000
Enter percentage: The percentage of employees with a salary greater than $50,000 but less
than or equal to $100,000. As used here, this is for union employees. The salary is including
bonuses.
EMPLOYEE INFORMATION
Union - Greater Than
$100,000
Enter percentage: The percentage of employees with a salary over $100,000. As used here,
this is for union employees. The salary is including bonuses.
EMPLOYEE INFORMATION
1. Does the applicant have
any employees located
outside the primary state of
operations, including
outside of the United
States?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Does the applicant have any employees located outside the primary state of operations,
including outside of the United States?. As used here, if Yes, list the state or country and the
number of employees.
EMPLOYEE INFORMATION
State
Enter code: The state or province code where the employees are located.
EMPLOYEE INFORMATION
Country
Enter code: The country code where the employees are located.
EMPLOYEE INFORMATION
Number Of Employees
Enter number: The total number of employees in the state, province or country.
EMPLOYEE INFORMATION
State
Enter code: The state or province code where the employees are located.
EMPLOYEE INFORMATION
Country
Enter code: The country code where the employees are located.
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EMPLOYEE INFORMATION
Number Of Employees
Enter number: The total number of employees in the state, province or country.
EMPLOYEE INFORMATION
State
Enter code: The state or province code where the employees are located.
EMPLOYEE INFORMATION
Country
Enter code: The country code where the employees are located.
EMPLOYEE INFORMATION
Number Of Employees
Enter number: The total number of employees in the state, province or country.
EMPLOYEE INFORMATION
State
Enter code: The state or province code where the employees are located.
EMPLOYEE INFORMATION
Country
Enter code: The country code where the employees are located.
EMPLOYEE INFORMATION
Number Of Employees
Enter number: The total number of employees in the state, province or country.
EMPLOYEE INFORMATION
2. Does the applicant have a
tracking system that
monitors the overtime,
vacation and sick pay hours
of non-exempt employees?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Does the applicant have a tracking system that monitors the overtime, vacation and sick pay
hours of non-exempt employees?.
EMPLOYEE INFORMATION
3. Were any employees or
officers terminated or do
you plan in the next 18
months to terminate any
employees or officers?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Were any employees or officers terminated or do you plan in the next 18 months to terminate
any employees or officers?. As used here, if Yes, enter how many and provide details.
EMPLOYEE INFORMATION
How Many?
Enter number: The number of employees or officers terminated in the specified period of time.
EMPLOYEE INFORMATION
Provide Details
Enter text: An explanation as to whether there have been any employees or officers terminated
or any plans to terminate any employees or officers in the next 18 months.
REMARKS
Remarks
Enter text: The general remarks associated with the employment related practices liability line of
business. List any additional, pertinent information that the underwriter should know about the
overall exposures of this risk.
Form Page 2
Section Name
Field Name
Description
IDENTIFICATION SECTION
Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g., agency or
brokerage).
FINANCIAL INFORMATION
Date of Financial
Information
Enter date: The date the financial information was prepared. (MM/DD/YYYY)
FINANCIAL INFORMATION
Period of Financial
Information From
Enter date: The starting date of the financial information. (MM/DD/YYYY)
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FINANCIAL INFORMATION
Period of Financial
Information To
Enter date: The end date of the financial information. (MM/DD/YYYY)
FINANCIAL INFORMATION
Outside Auditor
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Outside Auditor?.
FINANCIAL INFORMATION
1. Any changes to the
outside financial auditor in
the last three (3) years? (Y /
N)
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Any changes to the outside financial auditor in the last specified number of years?.
FINANCIAL INFORMATION
2. Has any auditor issued a
Going Concern opinion
for the applicants or any of
its subsidiaries financial
statements? (Y / N)
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Has any auditor issued a Going Concern opinion for the applicants or any of its subsidiaries
financial statements?.
FINANCIAL INFORMATION
Current Year:
Enter year: The year of the current financial information.
FINANCIAL INFORMATION
Current Year: Total Assets
Enter amount: The total assets of the organization for the current year.
FINANCIAL INFORMATION
Current Year: Current
Assets
Enter amount: The amount of assets that are cash or are convertible into cash at short notice for
the current year.
FINANCIAL INFORMATION
Current Year: Inventory
Enter amount: The inventory amount for the current year.
FINANCIAL INFORMATION
Current Year: Cash
Enter amount: The cash amount for the current year.
FINANCIAL INFORMATION
Current Year: Current
Liabilities
Enter amount: The amount of debt that becomes due within one year for the current year.
FINANCIAL INFORMATION
Current Year: Total
Liabilities
Enter amount: The total liabilities of the organization for the current year.
FINANCIAL INFORMATION
Current Year: Total Revenue
Enter amount: The total revenue for the organization for the current year.
FINANCIAL INFORMATION
Current Year: Net Income /
Loss
Enter amount: The excess amount of revenue over expenses for the current year. This may be
a net loss amount.
FINANCIAL INFORMATION
Prior Year:
Enter year: The year of the prior financial information.
FINANCIAL INFORMATION
Prior Year: Total Assets
Enter amount: The total assets of the organization for the prior year.
FINANCIAL INFORMATION
Prior Year: Current Assets
Enter amount: The amount of assets that are cash or are convertible into cash at short notice for
the prior year.
FINANCIAL INFORMATION
Prior Year: Inventory
Enter amount: The inventory amount for the prior year.
FINANCIAL INFORMATION
Prior Year: Cash
Enter amount: The cash amount for the prior year.
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FINANCIAL INFORMATION
Prior Year: Current
Liabilities
Enter amount: The amount of debt that becomes due within one year for the prior year.
FINANCIAL INFORMATION
Prior Year: Total Liabilities
Enter amount: The total liabilities of the organization for the prior year.
FINANCIAL INFORMATION
Prior Year: Total Revenue
Enter amount: The total revenue for the organization for the prior year.
FINANCIAL INFORMATION
Prior Year: Net Income /
Loss
Enter amount: The excess amount of revenue over expenses for the prior year. This may be a
net loss amount.
CORPORATE HISTORY
1. Has the applicant had any
actual or attempted merger,
acquisition, consolidation or
divestment in the past six
(6) years or anticipated in
the next 18 months?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Has the applicant had any actual or attempted merger, acquisition, consolidation or divestment
in the past mandated number of years or anticipated in the next mandated number of months?.
CORPORATE HISTORY
If Yes, provide actual or
anticipated date of action
and details.
Enter text: An explanation as to whether the applicant has had any actual or attempted merger,
acquisition, consolidation or divestment in the past six (6) years or anticipated in the next 18
months. If YES, provide actual or anticipated date of action.
CORPORATE HISTORY
2. Has the applicant in the
past 36 months completed
or agreed to, or anticipate
within the next 18 months,
any plant, facility, branch or
office closings,
consolidations or layoffs?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Has the applicant in the past mandated time completed or agreed to, or does it anticipate within
the next mandated time, any plant, facility, branch or office closings, consolidations or layoffs?.
CORPORATE HISTORY
If Yes, provide actual or
anticipated date of action
and details.
Enter text: An explanation as to whether the applicant has completed or agreed to or anticipates
within the next 18 months, any plant, facility, branch or office closings, consolidations or layoffs.
If YES, provide actual or anticipated date of action.
CORPORATE HISTORY
1. Does the applicant have a
human resources
department?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Does the applicant have a human resources department?. As used here, if Yes, enter the
number of employees. If No, enter the name of the person handling this function.
CORPORATE HISTORY
Number of Employees
Enter number: The number of human resources employees.
CORPORATE HISTORY
Human Resource Function
Enter text: The full name of the person handling human resources functions.
EMPLOYMENT POLICIES /
PROCEDURES
a. Human Resources
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Does the applicant require employment terminations to be reviewed by human resources?.
EMPLOYMENT POLICIES /
PROCEDURES
b. Legal Department
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Does the applicant require employment terminations to be reviewed by the legal department?.
EMPLOYMENT POLICIES /
PROCEDURES
c. Outside Legal Counsel
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Does the applicant require employment terminations to be reviewed by outside legal counsel?.
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EMPLOYMENT POLICIES /
PROCEDURES
3. What outside employment
legal counsel does the
applicant use for
employment and/or labor
advice and/or defense?
Enter text: The name of any outside employment legal counsel the applicant uses for
employment and/or labor advice and/or defense.
EMPLOYMENT POLICIES /
PROCEDURES
4. Does the applicant
conduct testing for:
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Does the applicant conduct any testing?. As used here, if Yes, check all that apply. If any
are checked, attach a copy of any written policies and procedures.
EMPLOYMENT POLICIES /
PROCEDURES
Drug / Alcohol Screening
Check the box (if applicable): Indicates the applicant conducts drug / alcohol screening.
EMPLOYMENT POLICIES /
PROCEDURES
Physical Examinations
Check the box (if applicable): Indicates the applicant conducts physical examinations.
EMPLOYMENT POLICIES /
PROCEDURES
Psychological Examinations
Check the box (if applicable): Indicates the applicant conducts psychological examinations.
EMPLOYMENT POLICIES /
PROCEDURES
Skills Testing
Check the box (if applicable): Indicates the applicant conducts skills testing.
EMPLOYMENT POLICIES /
PROCEDURES
Polygraph Testing
Check the box (if applicable): Indicates the applicant conducts polygraph testing.
EMPLOYMENT POLICIES /
PROCEDURES
Background Checks
Check the box (if applicable): Indicates the applicant conducts background checks.
EMPLOYMENT POLICIES /
PROCEDURES
Other
Check the box (if applicable): Indicates the applicant conducts testing other than those listed.
EMPLOYMENT POLICIES /
PROCEDURES
Describe Other
Enter text: The type of testing conducted by the applicant.
EMPLOYMENT POLICIES /
PROCEDURES
Individual Conducting the
Testing
Enter text: The full name of the individual conducting the testing.
EMPLOYMENT POLICIES /
PROCEDURES
Pre-Employment
Check the box (if applicable): Indicates testing / examinations are done pre-employment.
EMPLOYMENT POLICIES /
PROCEDURES
Post Offer Of Employment
Check the box (if applicable): Indicates testing / examinations are done after an offer of
employment.
EMPLOYMENT POLICIES /
PROCEDURES
5. Are all employees subject
to these tests and
examinations?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Are all employees subject to these tests and examinations?.
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EMPLOYMENT POLICIES /
PROCEDURES
If No, which employees
are not subject to these
tests and examinations and
why?
Enter text: An explanation as to which employees are not subject to these tests and
examinations and why.
EMPLOYMENT POLICIES /
PROCEDURES
6. Does the applicant use an
employment application for
all applicants?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Does the applicant use an employment application for all applicants?.
EMPLOYMENT POLICIES /
PROCEDURES
If No, which applicants are
not required to complete an
application and then how is
the hiring process
conducted?
Enter text: An explanation as to which applicants are not required to complete an employment
application and how the hiring process is then conducted.
EMPLOYMENT POLICIES /
PROCEDURES
7. Does the applicant utilize
standard offer letters for all
applicants?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Does the applicant utilize standard offer letters for all applicants?.
EMPLOYMENT POLICIES /
PROCEDURES
If No, which applicants are
not provided with
employment offer letters
and why?
Enter text: An explanation as to which applicants are not provided with employment offer letters
and why.
EMPLOYMENT POLICIES /
PROCEDURES
8. Does the applicant have a
formal orientation program
for all new employees?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Does the applicant have a formal orientation program for all new employees?.
EMPLOYMENT POLICIES /
PROCEDURES
9. Does the applicant
provide annual written
performance evaluations for
all employees?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Does the applicant provide annual written performance evaluations for all employees?.
EMPLOYMENT POLICIES /
PROCEDURES
If Yes, does it include
standard rating categories?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Do written performance evaluations include standard rating categories?.
EMPLOYMENT POLICIES /
PROCEDURES
10. Does the applicant
conduct training on sexual
harassment and
discrimination prevention?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Does the applicant conduct training on sexual harassment and discrimination prevention?.
EMPLOYMENT POLICIES /
PROCEDURES
a. Who is required to
attend?
Enter text: The description of who is required to attend sexual harassment and discrimination
prevention training.
EMPLOYMENT POLICIES /
PROCEDURES
b. How often is it held?
Enter text: The frequency of sexual harassment and discrimination prevention training.
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EMPLOYMENT POLICIES /
PROCEDURES
c. Who conducts the
training?
Enter text: The full name of the person conducting sexual harassment and discrimination
prevention training.
EMPLOYMENT POLICIES /
PROCEDURES
d. Is training documented?
Enter text: The description of how the training is documented.
Form Page 3
Section Name
Field Name
Description
IDENTIFICATION SECTION
Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g., agency or
brokerage).
EMPLOYMENT POLICIES /
PROCEDURES
11. Does the applicant have
a formal contract with any
employee?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Does the applicant have a formal contract with any employee?. If Yes, provide a specimen
copy of the employment contract(s).
EMPLOYMENT POLICIES /
PROCEDURES
If Yes, is/are employment
contract(s) created and
reviewed by outside
counsel?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Are employment contracts created and reviewed by outside counsel?.
EMPLOYMENT POLICIES /
PROCEDURES
Total Number Of Employees
With A Formal Employment
Contract
Enter number: The total number of employees with a formal employment contract.
EMPLOYMENT POLICIES /
PROCEDURES
Total Value Of All Contracts
Enter amount: The total value of all employment contracts.
EMPLOYMENT POLICIES /
PROCEDURES
Total Value Of Largest
Contract
Enter amount: The total value of the largest employment contract.
EMPLOYMENT POLICIES /
PROCEDURES
12. Does the applicant have
an employee handbook?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Does the applicant have an employee handbook?.
EMPLOYMENT POLICIES /
PROCEDURES
If Yes, is it distributed to
all employees?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Do you distribute an employment handbook to all employees?.
EMPLOYMENT POLICIES /
PROCEDURES
13. Do all employees
provide a written
acknowledgement that they
have received the
handbook?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Do all employees provide a written acknowledgement that they have received the handbook?.
EMPLOYMENT POLICIES /
PROCEDURES
14. Is the employee
handbook uniform for all
locations and subsidiaries?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Is the employee handbook uniform for all locations and subsidiaries?.
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EMPLOYMENT POLICIES /
PROCEDURES
15. Has an employment
attorney reviewed the
employee handbook?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Has an employment attorney reviewed the employee handbook?.
EMPLOYMENT POLICIES /
PROCEDURES
Date Last Reviewed
Enter date: The date the employee handbook was last reviewed.
EMPLOYMENT POLICIES /
PROCEDURES
16. Are uniform exit
interviews conducted when
an employee resigns or is
terminated (voluntary and
involuntary)?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Are uniform exit interviews conducted when an employee resigns or is terminated (voluntary
and involuntary)?.
EMPLOYMENT POLICIES /
PROCEDURES
If Yes, are exit interviews
documented?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Are exit interviews documented?.
EMPLOYMENT POLICIES /
PROCEDURES
17. Is the applicant required
to file an affirmative action
plan with the Office of
Federal Contract
Compliance Programs
(OFCCP)?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Is the applicant required to file an affirmative action plan with the Office of Federal Contract
Compliance Programs (OFCCP)?.
EMPLOYMENT POLICIES /
PROCEDURES
18. Has the applicant ever
been the subject of an
OFCCP investigation which
resulted in the finding of a
violation?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Has the applicant ever been the subject of an OFCCP Investigation which resulted in the
finding of a violation?.
EMPLOYMENT POLICIES /
PROCEDURES
19. Does the applicant
utilize arbitration for
employment- related
claims?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Does the applicant utilize arbitration for employment-related claims?.
EMPLOYMENT POLICIES /
PROCEDURES
20. Is arbitration for
employment - related claims
mandatory?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Is arbitration for employment-related claims mandatory?.
EMPLOYMENT POLICIES /
PROCEDURES
21. Are all applicant's
locations compliant with the
Americans with Disabilities
Act (ADA)?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Are all applicant's locations compliant with the Americans with Disabilities Act (ADA)?.
EMPLOYMENT POLICIES /
PROCEDURES
If No, provide details.
Enter text: An explanation as to which applicant's locations are not compliant with the Americans
with Disabilities Act ( ADA) and provide details.
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GENERAL INFORMATION
1. Has any insured been
involved in a civil or
criminal action,
administrative proceeding,
investigation or charging
violation by the Equal
Employment Opportunity
Commission (EEOC) or
similar federal, state or
foreign employment law or
regulation?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Has any insured been involved in a civil or criminal action, administrative proceedings,
investigation or charging violation by the Equal Employment Opportunity Commission (EEOC) or
similar federal, state or foreign employment law or regulation?.
GENERAL INFORMATION
Explanation
Enter text: An explanation as to whether any insured has been involved in a civil or criminal
action, administrative proceeding, investigation or charging violation by the Equal Employment
Opportunity Commission (EEOC) or similar federal, state or foreign employment law or
regulation.
GENERAL INFORMATION
2. Has any insured been
involved in any other
criminal actions?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Has any insured been involved in any other criminal actions?.
GENERAL INFORMATION
Explanation
Enter text: An explanation as to whether any insured has been involved in any other criminal
actions.
GENERAL INFORMATION
3. Has any insured been
involved in any
representative actions,
class actions or derivative
suits in connection with
employment issues?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Has any insured been involved in any representative actions, class actions or derivative suits in
connection with employment issues?.
GENERAL INFORMATION
Explanation
Enter text: An explanation as to whether any insured has been involved in any representative
actions, class actions or derivative suits in connection with employment issues.
GENERAL INFORMATION
4. Is any insured presently
subject to any judicial or
administrative order,
decree, judgment or
conciliation agreement that
is employment - related?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Is any insured presently subject to any judicial or administrative order, decree, judgment or
conciliation agreement that is employment-related?.
GENERAL INFORMATION
Explanation
Enter text: An explanation as to whether any insured is presently subject to any judicial or
administrative order, decree, judgment or conciliation agreement that is employment-related.
REMARKS
Additional Remarks
Enter text: The general remarks associated with the employment related practices liability line of
business. List any additional, pertinent information that the underwriter should know about the
overall exposures of this risk.
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Form Page 4
Section Name
Field Name
Description
IDENTIFICATION SECTION
Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g., agency or
brokerage).
SIGNATURE
Producer's Signature
Sign here: Accommodates the signature of the authorized representative (e.g., producer, agent,
broker, etc.) of the company(ies) listed on the document. This is required in most states.
SIGNATURE
Producer's Name
Enter text: The name of the authorized representative of the producer, agency and/or broker
that signed the form.
SIGNATURE
State Producer License No
(Required in Florida)
Enter identifier: The State License Number of the producer.
SIGNATURE
Applicant's Signature
Sign here: Accommodates the signature of the applicant or named insured.
SIGNATURE
Date
Enter date: The date the form was signed by the named insured. (MM/DD/YYYY)
SIGNATURE
National Producer Number
Enter identifier: The National Producer Number (NPN) as defined in the National Insurance
Producer Registry (NIPR). Note: The NPN is not the same as the producer state license
number.
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