ICC EB APP 04 08
ILLINOIS CASUALTY COMPANY
A Mutual Insurance Company
225 20th Street, PO Box 5018, Rock Island, IL 61204-5018
309-793-1700 800-445-3726 FAX: 309-793-1707
EMPLOYEE BENEFITS LIABILITY COVERAGE QUESTIONNAIRE
1. Policy/Quote # _____________________________________________________________
2. Name of Applicant (Insured) ___________________________________________________
3. Limits Desired: $ ________________ Each Employee: $ _____________ Aggregate
Policy is subject to a $1,000 deductible per claim.
4. Policy Period: From ______________ To ________________
Retroactive Date: ___________________________________
If the retroactive date is prior to the policy effective date, provide a copy of the prior coverage
showing the retroactive date.
5. Number of Employees under programs administered _______________________________
6. Employee Benefit Programs which are covered are (check all applicable):
Group Life Insurance Group Accident or Health InsuranceGroup Dental Insurance
Group Optical InsuranceProfit Sharing Plans
Employee Stock Subscription PlansSalary Continuation Plans
Workers’ Compensation
Unemployment Insurance Social Security and Disability Benefits Insurance
Travel, Savings or Vacation Programs
Salary Administration Plans are not covered.
7. Are benefit plans jointly administered (i.e., trustees elected or appointed by management and
union)?
Yes No
8. Are benefit plans administered by an outside third party administrator?
Yes No
If “Yes”, name of Administrator _______________________________________; and do they
carry errors and omissions liability insurance?
Yes No
9. On programs permitting employees an option to enroll or not to enroll, does the applicant
require a signed acceptance or rejection from each employee?
Yes No
If “No”, explain ______________________________________________________________
__________________________________________________________________________
10. If this insurance had been in force during the past five years, would any claim have been
presented? (Give details) _____________________________________________________
__________________________________________________________________________
__________________________________________________________________________
11. Does the applicant have knowledge or information of any occurrence which might give rise to
a claim? __________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
Prior to binding coverage we will need documentation confirming the retroactive date from the
most recent prior carrier.
