APPLICATION FOR EMPLOYMENT PRACTICES
LIABILITY INSURANCE
PLEASE NOTE:
• Employment Practices Liability Insurance is written on a claims-made basis and covers only Claims first made
against the Insured Persons during the Policy Period or the Extended Reporting Period, if exercised. The Limit of
Liability available to pay judgments or settlements shall be reduced by amounts incurred as Defense Costs.
• This application and all exhibits attached shall form a part of this proposal and shall be held in strictest confidence.
The following material must be attached to this application:
1. EEO-1 Report (consolidated for the past three (3) years)
2. Latest 10K Report/Latest Annual Report
3. Employee Handbook/Manual (including copies of Sexual Harassment Policy, ADA Policy, Family Medical Leave Policy,
Termination Procedures and Progressive Disciplinary Policies), EEO Statement, At-Will Policy
4. Employment Applicant Forms
5. Employee Performance Evaluation Forms
6. Affirmative Action Plan (if applicable)
Please indicate if any of the materials requested above are not attached to this application and the reason why.
The following material must be attached to this application (if applicable):
1. Foreign Operational Information Supplemental Form
2. Claim Information Supplemental Form
3. Downsizing/Layoff Information Supplemental
This application is submitted by:
Insurance Agency/Agent: __________________________________________________________________________________
Address: __________________________________________________________________________________
Please submit this completed proposal Application with all attachments to:
Zurich-American Specialties
Executive Assurance Department
One Liberty Plaza, 30th Floor
New York, New York 10006
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Page 1 of 11
Please answer all of the following questions and indicate if a question is not applicable.
1.
GENERAL INFORMATION
A. (1) Name of Parent Company _______________________________________________________________________
(2) Address _____________________________________________________________________________________
City/State/Zip ________________________________________________________________________________
(3) Date Incorporated _____________________________________________________________________________
Corporation Professional Corporation Proprietorship Other (specify) __________________________
(4) Standard Industrial Code _______________________________________________________________________
(5) Please provide a brief description of major Products/Services of the Company______________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
(6) On a separate sheet, please attach a list of subsidiaries proposed for coverage. Please include the nature of business
and the percentage owned by the Parent Company.
(7) Are there any operations outside the United States or Canada for which coverage is desired? Yes No If yes,
please complete and attach the Foreign Operations Supplement.
B. Provide Coverage Desired - Limit of Liability: ________________________ Retention: _______________________
C. Prior Employment Practices Liability Insurance (EPLI) or Human Resources Practices (HPR) coverage for the past three
(3) years:
PERIOD INSURER PREMIUM LIMIT
D. Have you ever been canceled or nonrenewed for this coverage? (Missouri applicants are not required to answer this
question.) Yes No
E. Is EPLI coverage currently provided under your Commercial General Liability or Directors and Officers Liability cover-
age? Yes No
2.
LOSS HISTORY
A. Complete the Claim Supplemental for any claim(s) in which the total defense costs and judgments, settlements, or other
costs exceeded, or is expected to exceed $10,000. If there are no claims, state NONE. ___________________________
B. Are you aware of any fact(s), incident(s), act(s), event(s), or circumstance(s) that may result in any claim(s) being made
against you? Yes No If yes, please provide details on a separate sheet. (Include Open/Closed EEOC charges
within last 5 years.)
It is agreed that if such fact, incident, act, event, or circumstance exists, whether or not disclosed, any claim arising
therefrom is excluded from this proposed coverage.
U-EPL-1158-A
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3.
EMPLOYEES
A. Please provide current number of employees by state/country. For additional states attach a separate sheet.
State/Country Breakdown # of Full Time Employees # of Part Time Employees
1.
2.
3.
4.
5.
Total
B. What percentage of your workforce is unionized? _____________%
C. For each of the past five years, what has been your annual percentage of turnover rate of employees. ( Turnover rate
should be calculated as follows: number of separations during the month divided by average number of employees on
payroll during the month x 12.)
Year Annual % Rate of
Employee Turnover
D. Percentage of employees with salaries (including bonuses):
Less than $50,000: ________%
$50,001 - $100,000: ________%
$100,001 - $250,000: ________%
Greater than $250,000: ________%
4.
EMPLOYMENT PRACTICES PROCEDURES
A. Does the Parent Company have a Human Resources or Personnel Department? Yes No If no, who performs the
human resources functions? (Please provide details on what personnel are involved in performing human resources
func-
tions.)___________________________________________________________________________________________
____________________________________________________________________________________________
1. Please provide the name and contact information for the HR contact.?
____________________________________________________________________________________________________
Name Phone E-mail Address
B. Please describe the reporting relationship of the Human Resources Department, or person(s) performing this function, to
Senior Management:_____________________________________________________________________________
________________________________________________________________________________________________
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C. Does the Parent Company use an employment application for all applicants? Yes No If no, which employees are
not required to use one and how is the hiring process conducted?____________________________________________
________________________________________________________________________________________________
D. Is the application uniform at all company locations and subsidiaries? Yes No
E. Does the Parent Company have a formal orientation program for all new employees? Yes No If yes, is an orienta-
tion checklist maintained for each? Yes No
F. Does the Parent Company provide regular, written performance evaluations for all employees? Yes No
G. Does the Parent Company conduct drug/medical testing for all employees? Yes No If yes, please complete the fol-
lowing section. If no, then skip to Question J.
Indicate which types of tests are administered:
Drug/Alcohol screening Physical Exams Psychological Exams Skills (clerical, trade, etc.)
Other (please specify): ____________________________________________________________________________
H. When are the tests conducted? Pre-job Offer Post-job Offer
I. Are all employees required to undergo these exams? Yes No If no, please state which employees are not
tested:___________________________________________________________________________________________
J. Does the Parent Company publish an employment handbook? Yes No If yes, is it distributed to all employees?
Yes No
K. Is the handbook uniform for all company locations and subsidiaries? Yes No
L. Please indicate which of the following policies you currently have in place:
Indicate which are in the
Employee Handbook.
1. EEO Policy
2. At-will statement
3. Sexual Harassment Policy/Procedure
4. Progressive Discipline
5. FMLA Policy
6. Pregnancy Leave Policy
7. Grievance Procedures
8. ADA Policy Requiring Reasonable Accommodation
9. AIDS/HIV, Life Threatening Illnesses
M. Does the Parent Company require terminations to be reviewed by the following:
(1) Human Resources Department? Yes No
(2) Legal Department? Yes No
(3) Outside Counsel? Yes No
N. Does the Parent Company have a formal out-placement program which assists terminated or laid off employees in find-
ing other jobs? Yes No
O. Does the Parent Company conduct sensitivity training or other discrimination or sexual harassment prevention educa-
tion? Yes No If yes, who is required to attend and when was it last held?_________________________________
________________________________________________________________________________________________
P. 1. Do all employees have access to:
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(a) Voice Mail Yes No (b) E-Mail Yes No
2. If the Parent Company does make E-Mail available to employees, does the Parent Company have a policy on its use
by employees? Yes No
3. If the Parent Company does make Voice Mail available to employees, does the Parent Company have a policy on its
use by the employees? Yes No
4. Does the Parent Company have a written policy on the retention of the following types of electronic data:
(a) Computer data? Yes No
(b) E-Mail data? Yes No
(c) Voice Mail? Yes No
Q. Is the Parent Company required to file an Affirmative Action Plan with the OFCCP? Yes No
(a) If yes, has the Parent Company ever been, or is there, any investigation or inquiry by the OFCCP that has resulted in
a violation? Yes No If yes, attach a copy of the audit and state what action has been taken to remedy the vio-
lation.
(b) Does the Parent Company (or outside counsel or consultants) monitor the adverse impact on employees of the Par-
ent Company's personnel practices? Yes No
R. Does the Parent Company require mandatory arbitration of employment and labor related claims? Yes No
5.
CORPORATE HISTORY
If you answer Yes to any of the following, please attach details on a separate piece of paper.
A. Has the Parent Company acquired any companies in the past three years? Yes No
B. Did the purchase include assumption of employment liabilities? Yes No
C. With respect to acquired companies, were any employees or officers terminated or does the Parent Company plan
in the next 18 months to terminate any employees or officers? Yes No
D. Has the Parent Company sold any companies in the last three years? Yes No
If yes, did the Parent Company transfer the liabilities? Yes No
E. Does the Parent Company anticipate any plant, facility, branch or office closings, consolidations or layoffs within
the next 12 months? Yes No
Have there been any plant, facility, branch or office closings, consolidations or layoffs within the previous 12 months?
Yes No If yes, please complete and attach the Downsizing/Layoff Supplement.
F. Does the Parent Company anticipate any mergers or acquisitions in the next 18 months? Yes No
6.
CLAIMS HANDLING
1. Who in the Parent Company organization has been designated to handle employment claims?
____________________________________________________________________________________________________
Name Address Phone
2. With respect to the investigation of claims, complaints, incidents, etc. does the Parent Company have a written proce-
dure for obtaining information? Yes No If yes, please attach a copy.
7.
CURRENT NON-EMPLOYMENT PRACTICES INSURANCE
Directors and Officers
Insurance
Commercial General
Liability Insurance
Commercial Umbrella
Insurance
Insurer
Limit of Liability
Premium
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Expiration Date
8.
CONTINUITY WITH PRIOR COVERAGE
If the Parent Company has employment practices liability coverage and is requesting continuity of coverage for an existing
layer of coverage, please complete this Section and skip Section 9. If the Parent Company does not currently have liability
coverage, or this application is being submitted for a new excess limit of liability or the request for continuity of coverage for
an existing layer has been declined, please skip this Section and complete Section 9.
C
ontinuity date requested _________________________
Attach a copy of the prior application with which continuity of coverage is to be maintained. The Underwriter will be rely-
ing upon the declarations and representations contained in such prior application and those declarations and representations
shall be considered to be incorporated in and form a part of the proposed policy.
9.
PRIOR KNOWLEDGE
P
lease complete the following paragraph:
No person proposed for coverage is aware of any fact or circumstance or any actual or alleged act, error or omission which
he or she has reason to believe might give rise to a future claim that would fall within the scope of the proposed coverage,
except (if no exceptions, please state) ____________________________________________________________________
__________________________________________________________________________________________________
It is agreed that if such fact or circumstance or actual or alleged act, error or omission exists, whether or not disclosed, any
claim arising therefrom is excluded from this proposed coverage.
10.
FALSE INFORMATION
FRAUD WARNINGS
AR Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents
false information in any application for insurance is guilty of a crime and may be subject to fines and confinement in
prison.
CO It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for
the purpose of defrauding or attempting to defraud the insurance company. Penalties may include imprisonment, fines,
denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly pro-
vides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or
attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds
shall be reported to the Colorado division of insurance within the department of regulatory agencies.
DC It is a crime to provide false or misleading information to an Insurer for the purpose of defrauding the Insurer or any
other person. Penalties include imprisonment and/or fine. In addition, an Insurer may deny insurance benefits if false
information materially related to a claim was provided by the applicant
FL Any person who knowingly and with intent to injure, defraud, or deceive any Insurer files a statement of claim or an
application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.
KY any person who knowingly and with intent to defraud any insurance company or other person files an application for
insurance containing any materially false information or conceals, for the purpose of misleading, information concerning
any fact material thereto commits a fraudulent insurance act, which is a crime.
LA Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly pre-
sents false information in an application for insurance is guilty of a crime and may be subject to fines and confine-
ment in prison.
ME It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the pur-
p
ose of defrauding the insurance company. Penalties may include imprisonment, fines or a denial of insurance
benefits.
U-EPL-1158-A
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NE
No misrepresentations or warranty made by the Insured or on his behalf in the negotiation or application of this
policy or contract of insurance shall defeat or void the policy or contract or effect the insurance company’s obliga-
tion under the policy or contract unless such misrepresentation or warranty:
1. Was material;
2. Was made knowingly with the intent to deceive;
3. Was relied and acted upon by the insurance company; and,
4. Deceived the insurance company to its injury
The breach of a warranty or condition in any contract or policy of insurance shall not void the policy or allow the
insurance company to avoid liability unless such breach exists at the time of the loss and contributes to the loss.
NJ Any person who includes any false or misleading information on an application for an insurance policy is subject to
criminal and civil penalties.
NM Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents
false information in an application for insurance is guilty of a crime and may be subject to civil and criminal penalties.
NY Any person who knowingly and with intent to defraud any insurance company or other person files an application for
insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading,
information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and shall also be
subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.
OH An person who, with intent to defraud or knowing that he is facilitating a fraud against an Insurer, submits an applica-
tion or files a claim containing a false or deceptive statement is guilty of insurance fraud.
OK WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any Insurer, makes any claim for
the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.
PA Any person who knowingly and with intent to defraud any insurance company or other person files an application for
insurance or statement of claim containing any materially false information or conceals for the purpose of misleading,
information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such
persons to criminal and civil penalties.
UT For your protection, Utah law requires the following appear on this form:
Any person who knowingly presents false or fraudulent underwriting information, files or causes to be filed a false or
fraudulent claim for disability compensation or medical benefits, or submits a false or fraudulent report of billing for
health care fees or other professional services is guilty of a crime and may be subject to fines and confinement in state
prison.
VA It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose
of defrauding the insurance company. Penalties include imprisonment, fines and denial of insurance benefits.
U-EPL-1158-A
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11.DECLARATIONS
AND SIGNATURE
The undersigned declares that to the best of his or her knowledge and belief the statements set forth herein are true. The
signing of this application does not bind the Underwriter, the Parent Company or its proposed Insured Persons to effect in-
surance. The undersigned agrees that this application and its attachments shall be the basis of the contract should a policy
be issued and shall be deemed attached to and shall form part of the policy. The Underwriter is hereby authorized to make
any investigation and inquiry in connection with this application that it deems necessary.
The undersigned, on behalf of all proposed Insured Persons, agrees that if the information in the declarations and represen-
tations contained in this application and its attachments materially changes between the date of this application and the in-
ception of the proposed coverage, the undersigned will immediately report in writing to the Underwriter such change, and
the Underwriter may withdraw or modify any outstanding quotations or agreements to bind coverage. The undersigned ac-
knowledges and agrees that the Underwriter's receipt of such written report, prior to inception of the proposed coverage, is a
condition precedent to coverage.
This application must be signed by the Chairman of the Board or President of the Parent Company.
Signature _____________________________________Title ______________________________ Date _____________
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APPLICATION SUPPLEMENTAL
Downsizing/Layoff Information Form
1. Date of Downsizing/Layoff: ____________________________________________________________________________
2. Number of employees that have been, or will be, effected: ____________________________________________________
3. How will the Downsizing/Layoff be implemented (e.g. store/plant closing, departmental, seniority, random, etc.):
4. Was, or is, severance available to all employees?
Yes No
5. Were, or are, the employees required to sign an release for the severance package?
Yes No
6. Are outplacement services provided?
Yes No
7. Are exit interviews conducted?
Yes No
8. Were any Claims filed, or are any expected to be filed, as a result of this Downsizing/Layoff?
Yes No
If Yes, please complete and attach the Claim Supplemental.
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APPLICATION SUPPLEMENTAL
Claim Information Form
1. Date Claim was made:
2. Nature of Claim:
3. Type of Claim: EEOC Lawsuit
Other (Please specify)
4. Name of Complainant(s):
5. Names of Defendant(s):
6. Status of Claim: Pending Closed
If Closed: What was the total damages paid? $
What were the total expenses paid: $
What was the date closed:
If Pending: What are the total costs to date? $
Is there a settlement demand? Yes No
If Yes, what is the amount? $
7. Please give a detailed description of the allegations in the claim(s): _____________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
8. What steps have been taken to reduce the chances of a similar claim in the future? ________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
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APPLICATION SUPPLEMENTAL
Foreign Operation Information Form
1.
GENERAL INFORMATION
A. Name of Entity: ___________________________________________________________________________________
B. Country of Operation(s): ____________________________________________________________________________
C. Business Relationship with the Parent Company: ________________________________________________________
D. Nature of Operation(s):_____________________________________________________________________________
________________________________________________________________________________________________
2.
EMPLOYEES
Please provide the current number of employees by state/country.
State/Country Breakdown # of Full Time
Employees
# of Part Time
Employees
# of Seasonal
Employees
1.
2.
3.
4.
5.
Total
3.
LOSS HISTORY
A. Please complete and attach the Claim Supplemental for any claims or circumstances for the past three years.
B. How will employment claims be investigated and managed in view of local employment laws and who are the parties
involved in the claims handling?
4.
EMPLOYMENT PRACTICES
Do these foreign operations utilize the same Human Resource Policies and Procedures as the United States operations?
Yes No If No, please attach any policies or procedures that are unique to the foreign operations.
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