Cox & Company Insurance Agency, Inc

Employment Practices Liability Insurance Quote

Contact Information

Name of Business:
Contact Name:
Address:
City:	State: Zip:
Business Phone:	Fax Number:
Contact Email Address:

Is your business currently covered by
an Employment Practices Liability Policy?

YES NO
Current Insurance Carrier:
Premium: $ Expiration Date:

Current number of Employees, including owners, partners,
officers and directors for the Headquarter state

Non-Union:

Full-Time	Part-Time	Temporary	Seasonal

Union:

Full-Time	Part-Time	Temporary	Seasonal

Total number of persons employed by the applicant
in each of the last 3 years (all locations)

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	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	$25,000
$200,000

Are the following published and distributed to all employees

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
coverage's 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 and independent contractors
b) Coverage for Punitive Damages; and Increased limits for earnings lost from $100 to $1,000 per day?			YES NO

Additional Comments

Please give any additional comments or questions

No coverage of any kind is bound or implied by submitting information via this online form

Information from you and other sources, such as your driving, claims and insurance histories, may be used to calculate an accurate price for your insurance.
We will not distribute information to other parties other than for insurance underwriting purposes.
By submitting this form, you agree to release us from any liability should this information be accidentally viewed by others.

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