Applicant may qualify for an INSTANT QUOTE by completing Section I below. Section II answers will be required prior to binding and are
subject to underwriting approval.
EPL 6/09
page 1 of 3
Employment Practices Liability Application - All States
This application is for a Claims Made policy. Please read your policy carefully. Defense costs shall be applied against the retention
and may reduce the limits of liability by 100%.”.
I. INSTANT QUOTE INFORMATION
Instant quote is not available for accounts with losses in the past five years. If there is a loss history, please complete Section I and submit details in a claim
supplement.
Applicant’s name: __________________________________________________________________________________________________________
Location address: __________________________________________________________________________________ q Same as mailing address
City: ______________________________________________________ State: ______________________ Zip: ________________________
Web address: ____________________________________________________________________________________________________________
Email address of primary contact:___________________________________________________________________________________________
Description of Operations:
Full-time employees ________ Part-time ________ Temporary/ Seasonal ______ Independent contractors ________ Leased ________
How many of the above are located in: California ___________ Florida ___________ Louisiana __________ Outside the U.S. _________
II. UNDERWRITING INFORMATION
1. Year established: ______________________________
2. Do more than 50% of all employees currently earn more than $100,000? q Yes q No
3. a) Is the applicant a subsidiary of another organization? q Yes q No
b) Is the applicant a franchisee of another organization? q Yes q No
c) Name of parent and/or franchisor and location _________________________________________________________
4. Does the applicant want any subsidiary(s) covered? If “Yes,” include employees in employee count above and provide: q Yes q No
a) Name of subsidiary(s) _______________________________________________________________________________
b) Is the subsidiary(s) at least 50% owned by the applicant? q Yes q No
c) Does the subsidiary(s) fall within the same class of business as the applicant? q Yes q No
5. Expiring policy: Retroactive date___________ Carrier ___________________ Limits ___________ Retention _________ Premium __________
Written Guideline Requirements:
a) Does each entity proposed for insurance have a written e-mail/internet policy currently in place or is
willing to implement one? q Yes q No
b) Does each entity proposed for insurance have a written anti-discrimination and anti-harassment policy
currently in place? q Yes q No
(Attach a statement of details for all “Yes” answers to the following questions)
6. a) Has any entity proposed for insurance closed, sold, merged-with or acquired any company in the past
12 months or anticipates doing so in the next 12 months? q Yes q No
b) Has any entity proposed for insurance downsized, laid off or reduced staff in the past 12 months or
anticipates doing so in the next 12 months? q Yes q No
If “Yes,” what percentage of the workforce was/will be affected? _________________
7. Within the last five years, has any employment related, or third party discrimination, or third party harassment
inquiry, complaint, notice of hearing, claim or suit been made against any entity proposed for insurance or
any person proposed for insurance in the capacity of either director, officer, member (if an LLC), or employee
of any entity proposed for insurance? If “Yes,” complete USLI Claim Supplement for each claim q Yes q No
8. Is any person proposed for this insurance aware of any fact, circumstance, or situation which may result in an
employment claim, or third party discrimination, or third party harassment claim against any entity proposed
for insurance or any of its directors, officers, members (if an LLC) or employees?
If “Yes,” complete USLI Claim Supplement for each claim q Yes q No
9. Has any policy for employment practices liability insurance ever been cancelled or non-renewed by the carrier? q Yes q No
(Do not answer if applicant is located in Missouri)
U
NITED
S
TATES
L
IABILITY
I
NSURANCE
G
ROUP
A BERKSHIRE HATHAWAY COMPANY
USLI.COM
888-523-5545
III. ADDITIONAL APPLICANT INFORMATION
Applicant’s mailing address: _________________________________________________________________________________________________
City: ______________________________________________________ State: ______________________ Zip: ________________________
Arizona Notice: Misrepresentations, omissions, concealment of facts and incorrect statements shall prevent recovery under the policy only if
the misrepresentations, omissions, concealment of facts or incorrect statements are; fraudulent or material either to the acceptance of the risk,
or to the hazard assumed by the insurer or the insurer in good faith would either not have issued the policy, or would not have issued a policy
in as large an amount, or would not have provided coverage with respect to the hazard resulting in the loss, if the true facts had been made
known to the insurer as required either by the application for the policy or otherwise.
Florida and Illinois Notice: I understand that there is no coverage for punitive damages assessed directly against an insured under Florida and
Illinois law. However, I also understand that punitive damages that are not assessed directly against an insured, also known as “vicariously assessed
punitive damages”, are insurable under Florida and Illinois law. Therefore, if any Policy is issued to the Applicant as a result of this Application and
such Policy provides coverage for punitive damages, I understand and acknowledge that the coverage for Claims brought in the State of Florida and
Illinois is limited to “vicariously assessed punitive damages” and that there is no coverage for directly assessed punitive damages
Minnesota Notice: Authorization or agreement to bind the insurance may be withdrawn or modified only based on changes to the information
contained in this application prior to the effective date of the insurance applied for that may render inaccurate, untrue or incomplete any
statement made with a minimum of 10 days notice given to the insured prior to the effective date of cancellation when the contract has been in
effect for less than 90 days or is being canceled for nonpayment of premium.
Missouri & Rhode Island Disclosure Notice: I understand and acknowledge that if a $100,000 or $250,000 Limit of Liability is chosen or if
the Insured Organization has more than 200 employees, that Defense Costs are a part of the Limit of Liability. This means that Defense Costs
will reduce my limits of insurance and may exhaust them completely and should that occur, I shall be liable for any further legal Defense Costs
and Damages. Defense Costs are as defined in Section III. I also understand that the Limit of Liability for the Extended Reporting Period, if
applicable, shall be a part of and not in addition to the limit specified in the Policy Declarations.
New York Disclosure Notice: This policy is written on a claims made basis and shall provide no coverage for claims arising out of incidents,
occurrences or alleged Wrongful Acts or Wrongful Employment Acts that took place prior to retroactive date, if any, stated on the declarations.
This policy shall cover only those claims made against an insured while the policy remains in effect for incidents reported during the Policy
Period or any subsequent renewal of this Policy or any extended reporting period and all coverage under the policy ceases upon termination
of the policy except for the automatic extended reporting period coverage unless the insured purchases additional extend reporting period
coverage. The policy includes an automatic 60 day extended claims reporting period following the termination of this policy. The Insured may
purchase for an additional premium an additional extended reporting period of 12 months, 24 months or 36 months following the termination of
this policy. Potential coverage gaps may arise upon the expiration for this extended reporting period. During the first several years of a claims-
made relationship, claims-made rates are comparatively lower than occurrence rates. The insured can expect substantial annual premium
increases independent overall rate increases until the claims-made relationship has matured.
Utah Notice: I understand that Punitive Damages are not insurable in the state of Utah. There will be no coverage afforded for Punitive
Damages for any Claim brought in the State of Utah. Any coverage for Punitive Damages will only apply if a Claim is filed in a state which
allows punitive or exemplary damages to be insurable. This may apply if a Claim is brought in another state by a subsidiary or additional
location(s) of the Named Insured, outside the state of Utah, for which coverage is sought under the same policy
Virginia Notice: This Policy is written on a claims-made basis. Please read the policy carefully to understand your coverage. You have an
option to purchase a separate limit of liability for the extended reporting period,. If you do not elect this option, the limit of liability for the extended
reporting period shall be part of the and not in addition to limit specified in the declarations. If you have any questions regarding the cost of an
extended reporting period, please contact your insurance company or your insurance agent. Statements in the application shall be deemed the
insured’s representations. A statement made in the application or in any affidavit made before or after a loss under the policy will not be deemed
material or invalidate coverage unless it is clearly proven that such statement was material to the risk when assumed and was untrue.
Colorado Fraud Statement: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company
for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil
damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or
information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a
settlement or award payable from insurance proceeds shall be reported to the Colorado division of insurance within the department of
regulatory agencies.
District of Columbia Fraud Statement: WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of
defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if
false information materially related to a claim was provided by the applicant.
Florida Fraud Statement: You are agreeing to place coverage in the surplus lines market. Superior coverage may be available in the
admitted market and at a lesser cost. Persons insured by surplus lines carriers are not protected under the Florida Insurance Guaranty Act with
respect to any right of recovery for the obligation of an insolvent unlicensed insurer.
Kentucky Fraud Statement: Any person who knowingly and with intent to defraud any insurance company or other person files an application
for insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material
thereto commits a fraudulent insurance act, which is a crime.
Maine and Washington Fraud Statement: It is a crime to knowingly provide false, incomplete or misleading information to an insurance
company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits.
New Jersey Fraud Statement: Any person who includes any false or misleading information on an application for an insurance policy is
subject to criminal and civil penalties.
Ohio Fraud Statement: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an
application or files a claim containing a false or deceptive statement is guilty of insurance fraud.
Oklahoma Fraud Statement: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any
claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.
Pennsylvania Fraud Statement: Any person who knowingly and with intent to defraud any insurance company or other person files an
application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information
concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil
penalties.
Tennessee and Virginia Fraud Statement: It is a crime to knowingly provide false, incomplete or misleading information to an insurance
company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.
Vermont Fraud Statement: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly
presents false information in an application for insurance may be subject to fines and confinement in prison.
Fraud Statement (All Other States): Any person who knowingly presents a false or fraudulent claim for
payment of a loss or benefit or knowingly presents false information in an application for insurance may be
guilty of a crime and may be subject to fines and confinement in prison.
EPL 6/09- United States Liability Insurance Group
page 2 of 3
If your state requires that we have information regarding your Authorized Retail Agent or Broker, please provide below.
Retail agency name:
_______________________________________________ License #: _________________________________________
Agent’s signature: _________________________________________________ Main agency phone number: _________________________
(Required in New Hampshire)
Agency mailing address:
______________________________________________________________________________________________
City: ____________________________________ State: ________________ Zip: ____________________________
The signer of this application acknowledges and understands that the information provided in this Application is material to the Insurer’s
decision to provide the requested insurance and is relied on by the Insurer in providing such insurance. The signer of this application
represents that the information provided in this Application is true and correct in all matters. The signer of this Application further represents
that any changes in matters inquired about in this Application occurring prior to the effective date of coverage, which render the information
provided herein untrue, incorrect or inaccurate in any way will be reported to the Insurer immediately in writing. The Insurer reserves the
right to modify or withdraw any quote or binder issued if such changes are material to the insurability or premium charged, based on the
Insurer’s underwriting guides. The Insurer is hereby authorized, but not required, to make any investigation and inquiry in connection with
the information, statements and disclosures provided in this Application. The decision of the Insurer not to make or to limit any investigation
or inquiry shall not be deemed a waiver of any rights by the Insurer and shall not estop the Insurer from relying on any statement in this
Application in the event the Policy is issued. It is agreed that this Application shall be the basis of the contract should a policy be issued and it
will be attached and become a part of the Policy.
New York Fraud Statement: Any person who knowingly and with intent to defraud any insurance company or other person files an application
for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information
concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and shall also be subject to a civil penalty not to
exceed five thousand dollars and the stated value of the claim for each such violation.
Applicant’s signature:
_______________________________________ Title: ______________________ Date: ______________________
President, Chairperson of the Board, Managing Member, or Executive Director
EPL 6/09- United States Liability Insurance Group
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