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 Business EPLI Quote 
Form:Employment Practices Liability Insurance Quote
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
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 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 byleased 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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    AMS Insurance
    442 W. Kortsen Rd #204
    Casa Grande, AZ 85222

    Toll Free: (800) 454-8148
     Phone: (520) 836-7517      fax: (520) 836-2071
     email: info@amsins.com


     

     

     

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