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Access E&S Insurance Services, Inc.
APPLICATION FOR
EMPLOYMENT PRACTICES LIABILITY INSURANCE
WITH THIRD-PARTY DISCRIMINATION COVERAGE
THIS IS AN APPLICATION FORM FOR A CLAIMS MADE POLICY
I. General Information
A. Name and address of Applicant:
B. Person to contact:
(name, title, telephone)
C. __Corporation __ Professional Corporation __Partnership __ Other
(Please specify)
N.A.I.C Code or SIC Code (If N.A.I.C Code is Unkown)
D. Describe nature of the Applicant’s business:
E. Number of other locations (
indicate states/countries):
F. Does the Applicant seek coverage for Subsidiaries (50% or more __Yes __No
owned and wholly controlled by the entity identified in “A” above)?
(If Yes, please identify Subsidiaries on a separate sheet and all
Application information should include information for each Subsidiary)
G. How long has the Applicant been in business? Years
H. How long has the Applicant been under current management? Years
Page 1 of 9
INSTRUCTIONS:
1. Answer all questions (if not applicable, show N/A) and attach all additional
information/explanations as required.
2. Applications must be dated and have two signatures.
3. “Applicant” refers to the company, its predecessors, and all proposed Insureds,
including Subsidiaries.
4. PLEASE READ STATEMENT AT END OF APPLICATION CAREFULLY.
I. In the past twelve (12) months, has your total number of employees decreased by more
than ten percent (10%) or five (5) employees, whichever is greater, through any
reduction in force, systematic lay-off or by closure of any division, office or facility that
you own or operate? __Yes __No
(If Yes, please complete the Reduction In Force supplement (I))
J. In the next twelve (12) months, do you anticipate the total number of your employees to
decrease by more than ten percent (10%) or five (5) employees, whichever is greater,
through any reduction in force, systematic lay-off or by closure of any division, office or
facility that you own or operate? __Yes __No
(If Yes, please complete the Reduction In Force supplement (J))
K. If, during the next 12 months, circumstances of which you are currently unaware make it
necessary for you to decrease the number of your Employees by ten percent (10%) or five
(5) Employees, whichever is greater, through the implementation of any reduction in
force, systematic lay-off or by closure of any division, office or facility that you own or
operate (with any such reduction, lay-off or closure not known, anticipated or planned by
you as of the date of this Application), do you agree that you will consult with, and adopt
the advice of, a lawyer who specializes in labor and employment law (may include in-
house counsel, but only if that counsel is qualified and experienced in the practice of
labor and employment law) as respects the implementation of such reduction, lay-off or
closure?
__Yes __ No
L. Does the Applicant anticipate any merger, acquisition, or addition of any operations that
would comprise a twenty five percent (25%) or ten (10) employees, whichever is
greater, increase over the current number of employees? __Yes __No
(If Yes, please provide full details on a separate sheet)
M. Has the proposed coverage ever been purchased before, whether __Yes __No
specifically or as a part of or addition to another coverage?
Year Type of Coverage Carrier Limit Deductible Premium
N. Has any insurer ever canceled or non-renewed the Applicant or its __Yes __No
predecessor for this type of coverage?
(If Yes, please provide details on a separate sheet)
II. Financial Information
A. Please answer the following four (4) questions for the Insured Company, including its
subsidiaries, for the most recent fiscal year end:
i) What are the Applicant’s total assets? $ __________________
ii) What are the Applicant’s total gross revenues? $ __________________
Page 2 of 9
iii) Does the Applicant currently have: Net Income __ or
Net Loss __
Amount $ ___________
iv) Does the Applicant currently have: Positive Cashflow __ or
Negative Cashflow __
Amount $ ________________________
B. Has an auditor in the previous two (2) fiscal years recommended a “going concern”
opinion of the financial information for the Applicant? __Yes __No
(If Yes, please provide details on a separate sheet)
III. Loss History
A. Furnish details of all Wrongful Employment Practice Claims
(as those terms are defined in the Policy) against the Applicant within the last 5
5 years.None__ See attached __(Please include all demands and lawsuits, as well as all
charges, inquiries, investigations, grievance or other proceedings before the Equal
Employment OpportunityCommission, or any other governmental agency with
responsibility for employment practices.)
Total number of Claims in the last 5 years
PLEASE PROVIDE A FULL DESCRIPTION OF EACH CLAIM ON A SEPARATE SHEET.
B. Does any director, officer, shareholder, principal, or employee __Yes __No
with personnel responsibility have knowledge of any circumstances
that could give rise to a Claim or in any other way suspect that a
Claim may be brought?
PLEASE PROVIDE A FULL DESCRIPTION OF EACH CIRCUMSTANCE ON A SEPARATE SHEET.
For example, but not by way of limitation, it would be reasonable for you to foresee that a Claim
may be brought against you if a current or former employee, including officers, or an applicant
for employment, has expressed dissatisfaction with the employment relationship or the
employment application process by:
i) making a formal complaint to an officer, principal, or supervisory employee of unfair
employment practices;
ii) otherwise complaining of discrimination, harassment, or unfair treatment;
iii) threatening to hire an attorney; or
iv) asking for a severance package in excess of what was offered.
The Applicant acknowledges that any Claims, or Claims later arising from
circumstances reported, or that should have been reported, in this Section II will be
excluded from coverage.
Page 3 of 9
IV. Employees (including Subsidiary employee information on a separate sheet)
A. Number of employees: Full Time: Part Time:
B. Salary ranges (including bonuses, Number of full Number of part
dividends and commissions) time employees time employees
$ 50,000 or less :
$ 50,001 to $100,000 :
$100,001 and over :
C. Does the Applicant use seasonal or temporary employees? __Yes __No
If so, when and how many?
Are these employees included in A and B above? __Yes __No
D. Does the Applicant use leased workers? __Yes __No
If yes, how many have been retained by the Applicant in the past
12 months?
Are these employees included in A and B above? __Yes __No
E. Does the Applicant use independent contractors? __Yes __No
If Yes, how many work solely for the Applicant?
F. How many employees are covered by collective bargaining or other union
agreements?
G. In the past 12 months, how many officers have left your employ?
Of the above, how many were terminated?
H. In the past 12 months, how many other employees have left your employ?
Of the above, how many were terminated?
V. Human Resources
A. Does the Applicant have written employment agreements with all __Yes __No
officers?
B. Have the Applicant’s managers and/or supervisors attended training __Yes __No
and education programs/seminars on sexual harassment and other types
of discrimination within the last 12 months?
If Yes, who has attended?
If Yes, who conducts the sessions?
C. Does the Applicant have its employment policies/procedures reviewed __Yes __No
by labor or employment counsel?
If Yes, identify the firm and date of last review:
Page 4 of 9
D. Does the Applicant have a Human Resources or Personnel Department? __Yes __No
If No, who handles this function
E. Does the Applicant have an employee handbook? __Yes __No
If Yes, does the Applicant distribute it to all employees? __Yes __No
If Yes, do all employees sign for its receipt? __Yes __No
If Yes, does it expressly state that it is not a contract and that __Yes __No
employment is “at will”?
F. Does the Applicant have written procedures for handling employee __Yes __No
complaints of discrimination and/or sexual harassment?
G. Does the Applicant require all terminations to be reviewed by:
The person in charge of human resources? __Yes __No
Outside counsel? __Yes __No
H. Does the Applicant maintain a personnel file for each employee? __Yes __No
VI. Third-Party Information
A. Estimated number of employees with customer/client contact:
B. Has the Applicant or its predecessors ever received a complaint, formal __Yes __No
or informal, from a non-employee, such as a customer, client, or
prospective customer or client complaining about discrimination or
harassment by the Applicant or any employee of the Applicant?
(If Yes, please provide details on a separate sheet)
C. Does the Applicant conduct staff training on client and customer __Yes __No
relations issues such as avoiding discriminatory behavior?
D. Are there procedures for reporting and dealing with complaints by __Yes __No
customers/clients?
E. Is the Applicant in compliance with Title III of the Americans with Yes No
Disabilities Act (building and premises requirements)?
VII. Other Material Facts
A. Please declare any other Material Facts on a separate sheet. None __ See
attached__
(If there are no other Material Facts, please check “None”)
A Material Fact is one likely to influence assessment of this risk, the premium charged or the
terms and conditions imposed by Underwriters. If you are in any doubt as to whether a fact would
be considered material, you should disclose it. All the information requested in this proposal is
material.
Please also ensure that any additional information is attached where
applicable.
Page 5 of 9
The Applicant warrants after full investigation and inquiry that the statements set forth
herein are true and include all material information.
The Applicant on behalf of all proposed Insureds further warrants that if the information
supplied on this application changes between the date of this application and the inception
date of the Policy, it will immediately notify Underwriters of such change. Signing of this
application does not bind Underwriters to offer, nor the Applicant to accept, insurance, but
it is agreed that this application shall be the basis of the insurance and will be attached and
made a part of the Policy should a policy be issued.
Date Signature of Applicant’s Authorized Principal or Officer Title
Date Signature of Applicant’s Authorized Human Resources Representative Title
(PLEASE NOTE THAT BOTH DATED SIGNATURES ARE
REQUIRED)
Page 6 of 9
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SUPPLEMENTAL CLAIM INFORMATION
Claimant(s):
Position/Title(s):
Defendant(s):
Position/Title(s):
Claim status: Incident Claim Suit
Venue:
(Court or
Agency)
Date of act(s) causing claim / incident:
Date claim / incident reported to the
applicant:
Nature of Claim and allegations:
Name of defense attorney and law firm:
Name of plaintiff attorney and law firm:
If Closed, total paid (defense and loss):
If Open:
1. Claimant's demand:
2. Insurer's defense and/or loss reserves:
3. Defense costs incurred to date:
4. Applicant's settlement offer:
5. Applicant's estimate of settlement:
Remedial action taken to prevent a similar claim:
Page 7 of 9
Reduction In Force Supplement (I)
A. How many employees were laid off? _____________________
B. What date(s) did the lay-off’s take place? _____________________
C. Did you consult with and follow the recommendations of a lawyer who specializes in
labor and employment law as respects the implementation of such reduction, lay-off or
closure? Yes No
D. Were severance packages offered to all laid-off employees? Yes No
E. Were signed releases gained from all laid-off employees? Yes No
F. Were exit interviews completed with all laid-off employees? Yes No
G. Did any of the laid off employees express that they were considering bringing any sort of
complaint or claim? Yes No
H. Please provide available details on the above.
Page 8 of 9
Reduction In Force Supplement (J)
A. How many employees will be laid off? _____________________
B. What date(s) will the lay-off be effective? _____________________
C. Do you agree to consult with and follow the recommendations of a lawyer who
specializes in labor and employment law as respects the implementation of such
reduction, lay-off or closure? Yes No
D. Will severance packages be offered to all laid-off employees? Yes No
E. Will signed releases be gained from all laid-off employees? Yes No
F. Will exit interviews be completed with all laid-off employees? Yes No
G. Please provide available details on the above.
Page 9 of 9
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Completed 8 January 2021

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