The Answer/corporate Directors & Officers Liability And Employment Practices Liability Application Form Page 2
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9.
Total number of employees.
Current
Prior
Anticipated next 12 months
12 months
12 months
(If operating less than 5 years)
Full Time:
______________
______________
______________________________________
Part Time:
______________
______________
______________________________________
Temporary/Seasonal:
______________
______________
______________________________________
Independent Contractors:
______________
______________
______________________________________
Leased:
______________
______________
______________________________________
10. Is more than 20% of the Organization's work force located in a state other than that shown in Item 1?
Yes
No
If yes, please provide the number of workers at each location.
11. Percentage of employees with total compensation including salaries, bonuses and commissions?
$51,000 to $100,000 __________________
Over $100,000 __________________
12. Has the Organization closed any facilities, downsized, laid off or reduced staff in the past 12 months?
Yes
No
Does the Organization anticipate doing so in the next 12 months?
Yes
No
If yes, please attach details.
13. Number of employees involuntarily terminated or laid off in the past 12 months?___________________ past 24 months? ____________
14. Within the last 5 years has any employment related, third party harassment or third party discrimination claim, suit, inquiry, complaint or
notice of hearing been made against the Organization or any individual proposed for Insurance?
Yes
No
If “Yes”, please complete a United States Liability Insurance Group claim supplement.
15. Within the last 5 years, has any claim, suit inquiry, complaint or notice of hearing been made against the Organization or any person
proposed for Insurance in the capacity of Director, Officer, or Employee of the Organization?
Yes
No
If “Yes”, please complete a United States Liability Insurance Group claim supplement.
16. Is any person or entity proposed for this Insurance aware of any fact, circumstance or situation which may result in a claim against the
Organization or any of its Directors, Officers, or Employees?
Yes
No
If “Yes”, please complete a United States Liability Insurance Group claim supplement.
Please complete the following if Employment Practices Liability requested:
Mandatory Written Employment Policies. Please identify policies Applicant has in place:
Anti-Harassment Policy
Yes
No
Anti-Discrimination Policy
Yes
No
Please forward copies of the policies identified above with this signed and dated application. If you do not have these written policies in place,
the Company will provide sample wording at the time of binding this insurance.
Policies must apply to employees and contractors, vendors, customers and other third parties if Third Party Discrimination
is purchased.
Recommended Written Employment Policies. Please identify policies Applicant has in place:
Employment Application
Yes
No
Employee Handbook
Yes
No
E-mail/Internet Policy
Yes
No
If Applicant has an Employee Handbook, Employment Application or E-Mail/Internet Policy, a copy of the Contractual Disclaimer and
Employment At Will statements in the Handbook, the employment application and the E-Mail/Internet Policy must be forwarded to the Company
for review.
As a condition precedent to issuance of the Policy for Insurance the Applicant agrees:
1.
to implement and distribute to each employee the Mandatory Written Policies identified above which are currently not in place as soon as
possible, but no later than 21 days after the inception date of this insurance. Failure of the Company to receive these policies within 21
days after the inception date of this insurance will result in rescission of the binder for this insurance.
2.
to adopt and distribute to each employee all changes required by the Company to the Applicant's Written Policies, as soon as possible, but
no later than 21 days after receipt of notice of the changes required by the Company.
page 2 of 3
CD APP 8/05
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