1. Name of Organization:

Primary Address of Location listed above

Additional Locations




Number of employees at each location

Are all locations listed to be covered by this insurance?


2. Purpose of Organization




3. Date Organized:

4. Are there any subsidiaries?

If Yes, provide name(s), date established, nature of operation, profit or nonprofit, purpose and percentage of ownership.




5. Does the Organization currently carry General Liability Insurance?

If Yes, which insurance Company?


6. Does the Organization currently carry Employment Practices Liability Insurance?

If Yes, please advise Insurance Company, limit of liability, expiring premium and number of years this insurance has been in force?




7. Total number of employees? (nonunion/union)

Full time

Part time

Temporary

Other


8. Salary Ranges of Full Time Employees including bonuses and commissions (specify by number of Employees);

$1 - $30,000:

$30,001 - $50,000:

$50,001 - $100,000:

$100,000 and greater:


9- Does the Organization have a written procedure for hiring and firing employees?

If Yes, please attach a copy.


10. Are any employees subject to a collective bargaining agreement?

If Yes, what percentage?


11. Does the Organization have a human resource person?

If Yes, is this position full time or part time?

If no, advise who handles the personnel function?


12. Does a lawyer or human resource person review involuntary employment terminations prior to termination of an employee?


13. Does the Organization have an internal grievance procedure for employment related disputes or complaints?


If yes, please advise details or attach a copy of the grievance procedure


14. Does the Organization have an Employment Handbook and/or written employment procedures?

If Yes, please attach a copy.

a. Does it include an "Employment at will" statement?

b. Does it state it is "not a contract of employment"?


15. Does the Organization have a written Sexual Harassment Guideline?

If Yes, please attach a copy.


16. Does the Organization have a written Anti-Discrimination (Equal Opportunity Employer) guideline?

If Yes, please attach a copy.


17. Has there been a reduction of employees in the past 12 months?

If Yes, what percentage?


18. Is a reduction of employees anticipated in the next 12 months?

If Yes, what percentage?


19. How many employees have been involuntarily terminated or layed off in the past 12 months?

in the past 24 months?


20. Has the Organization merged with or acquired a company in the past 12 months?

or does the Organization plan to do so in the next 12 months?

If Yes, please advise details.


21. Does the Organization have any contracts with or receive financial assistance from the Federal Government?

If Yes, please advise details:



22. Within the last 5 years, has the Organization or any individual proposed for insurance received any employment related inquiry, complaint or notice of hearing from any Municipal, State or Federal Regulatory Authority or Congressional or Legislative Committee (including, but not limited to, Equal Employment Opportunity Commission, E.E.O.C., and State Human Rights cases)?

If Yes, please explain



23. Within the last 5 years, has any employment related claim been made, or is any employment related claim of Sexual Harassment, Discrimination or Wrongful Termination now pending, against the Organization, or any person proposed for insurance in the capacity of either Director, Officer or Employee of the Organization?

IF YES, ADVISE ON A SEPARATE SHEET DETAILS OF THE CLAIM(S), INCLUDING DEFENSE COSTS INCURRED, DAMAGES PAID, WHETHER IT WAS COVERED BY INSURANCE AND REMEDIAL MEASURES TAKEN TO PREVENT A RECURRENCE OF SUCH CLAIM(S).


24. Is any person proposed for this Insurance aware of any fact, circumstance or situation which may result in an employment claim including, but not limited to, Sexual Harassment, Discrimination or Wrongful Termination against the Organization or any of its Directors, Officers, or Employees?

If Yes, please explain:



REQUIRED INFORMATION

A. Completed Application signed and dated by either the President or Chairman of the Board and Human Resource Director (or person handling this function).
B. Employment Handbook and/or written employment procedures, if any-
C. Copy of Employment Application.



Submit Completed Application Through Local Agent


Signature


Title
Date: