EPLI Application

Does the applicant currently carry any Employment Practices Liability coverage with The Hartford or any other carrier?

Yes

No

Is the applicant a subsidiary of a non-US Corporation?

Yes

No

Has the applicant experienced a merger, acquisition, sale of any assets or similar transaction?

Yes

No

Has the applicant experienced any financial restructuring, reorganization or filing for bankruptcy?

Yes

No

Has the applicant experienced any downsizing, layoffs, reduction in force, plant or office closings?

Yes

No

Does the applicant anticipate any of the preceding events within the next 12 months?

Yes

No

Is an employee handbook distributed to all employees?

Yes

No

Does the applicants employ any outside employment risk management services?

Yes

No

Do the applicants have a stand-alone Human Resources Department?

Yes

No

Has the applicant experienced any complaints, charges or hearings involving Employment Practices?

Yes

No

Does an Applicant or any natural person for whom insurance is intended have any knowledge or information of any error, misstatement, misleading statement, act, omission, neglect, breach of duty or other matter that may give rise to a claim?

Yes

No

Have there been any actual or potential lawsuits or claims that may fall within the scope of the coverage requested?

Yes

No

Has any Insurer cancelled or refused to renew any Directors and Officers, Employment Practices, Fiduciary, Crime, Kidnap Ransom or similar insurance within the past 36 months?

Yes

No

Are there any pending claims or demands against an Applicant or any natural person for whom this insurance is intended that may fall within the scope of coverage afforded by any previously or currently purchased insurance policy? (applicable to liability coverage parts only)

Yes

No

Has an Applicant or any natural person for whom this insurance is intended given notice under the provisions of any other previously or currently purchased insurance policy of any facts or circumstances which may give rise to a claim against any of them? (applicable to liability coverage parts only)

Yes

No

EPLI Application

Applicant Information

Company Information

In the past 24 months:

Employment Practices

Loss History & Prior Knowledge