Fillable EPL FI Application

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EPL FI Application

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Employment Practices Liability Application
*To be able to save this form after the elds are lled in, you will need to have Adobe Reader 9 or later. If you do not have
version 9 or later, please download the free tool at: http://get.adobe.com/reader/.
FDIC #: ___________________________
DATE: ___________________________
THE LIABILITY POLICY THAT MAY BE ISSUED BASED UPON THIS APPLICATION PROVIDES CLAIMS MADE
COVERAGE WRITTEN ON A NO DUTY TO DEFEND BASIS. DEFENSE COSTS ARE INCLUDED WITHIN THE LIMIT OF
LIABILITY AND REDUCE THE LIMIT OF LIABILITY AVAILABLE TO PAY SETTLEMENTS AND JUDGMENTS. PLEASE
READ THE POLICY CAREFULLY.
Applicant (Parent Company): __________________________________________________________________ FDIC #: ________________
Address: __________________________________________ City: _________________ State: ____________ Zip Code: ______________
P.O. Box : _________________________________________ City: _________________ State: ____________ Zip Code: ______________
Telephone: ________________________________________ Website: ________________________________
Representative authorized to receive notices on behalf of the applicant and all subsidiaries:
Name: ___________________________________________ Title: ___________________________ Email: __________________________
Contact Name/Email address of HR Manager or individual responsible for HR function (designated contact for our EPL Helpline/Loss
Control services):
Name: ___________________________________________ Title: ___________________________ Email: __________________________
For purposes of this Application for coverage, “Applicant” means the Parent Company and any Subsidiary listed below,
including any limited liability companies and joint ventures for which coverage is desired.
1. Total number of Employees: ________________________ Total number of locations: _____________________
2. Has employee turnover exceeded 25% in either of the past 2 years?
3. During the past 12 months, have there been or does the Applicant anticipate any employee layoffs,
terminations, branch/ofce closings, restructurings, layoffs, or reorganizations?
4. Does the Applicant have formal written policies with regard to discrimination and workplace harassment
(including a sexual harassment)?
5. Are all employment practices guidelines, policies and procedures reviewed by an employment law attorney?
6. Does the Applicant have written policies or procedures for dealing with complaints from the general public,
customers, clients, vendors or other third parties for issues involving harassment or discrimination?
7. Does the Applicant conduct training for employees on issues of discrimination and sexual and other
workplace harassment?
8. Within the past 2 years, has the Applicant or outside employment counsel completed an audit regarding the
payment of wages, including equal pay and overtime pay?
Part I. General Information
Part II. Current Coverage
Security National Insurance Company Wesco Insurance Company
AmTrust Insurance Company of Kansas
(all states except: AZ, CT, DE, FL, LA and NJ) (applies to: AZ, CT, DE, FL and NJ) (LA only)
Type of coverage: Carrier Limit Retention Premium Expiration
Employment Practices Liability: _____________ $ _____________ $ _____________ $ _____________ _____________
Part III. Employment Practices Information
APPL-BANC-EPL-01 0413 Page 1 of 3
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Part IV. Prior/Pending Litigation & Claims History
APPL-BANC-EPL-01 0413 Page 2 of 3
Fraud Warning
1. During the past 3 years, have there been any employment-related claims or administrative, criminal or
regulatory proceedings, charges, hearings, demands or lawsuits made against the Applicant or any person
proposed for this insurance, whether reimbursed or not?
2. Has any claim, demand or lawsuit been made against the Applicant or any person proposed for this
insurance involving sexual harassment or discrimination brought by the general public, customers, clients,
vendors or other third party?
3. New Applicants: Does the Applicant, any Subsidiary, any director or ofcer, or any other person proposed
for this insurance have knowledge of any fact, circumstance or situation which could reasonably be
expected to give rise a future employment-related claim?
Yes No
Yes No
Yes No
Any person who knowingly and with intent to defraud any insurance company or another person les 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 may be a crime and may subject the
person to criminal penalties.
ALABAMA, ARKANSAS, LOUISIANA, NEW JERSEY, NEW MEXICO, RHODE ISLAND, VIRGINIA and WEST VIRGINIA: Any person who knowingly presents a false or
fraudulent claim for payment of a loss or benet or knowingly presents false information in an Application for insurance is guilty of a crime. In Alabama, Arkansas, Louisiana, Rhode
Island and West Virginia that person may be subject to nes, imprisonment or both. In New Mexico, that person may be subject to civil nes and criminal penalties. In Virginia, penalties
may include imprisonment, nes and denial of insurance benets.
COLORADO: 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, nes, 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, KENTUCKY and PENNSYLVANIA: Any person who knowingly and with intent to defraud any insurance company or other person les an Application
for insurance or statement of claim containing 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. In District of Columbia, penalties include imprisonment and/or nes. In addition, the Insurer may deny insurance benets if the Applicant
provides false information materially related to a claim. In Pennsylvania, the person may also be subject to criminal and civil penalties.
FLORIDA and OKLAHOMA: Any person who knowingly and with intent to injure, defraud or deceive the Insurer, les a statement of claim or an Application containing any false,
incomplete or misleading information is guilty of a felony. In Florida it is a felony to the third degree.
KANSAS: An act committed by any person who, knowingly and with intent to defraud, presents, causes to be presented or prepares with knowledge or belief that it will be presented
to or by an Insurer, purported Insurer, broker or any agent thereof, any written statement as part of, or in support of, an application for the issuance of, or the rating of an insurance policy
for personal or commercial insurance, or a claim for payment or other benet pursuant to an insurance policy for personal or commercial insurance which such person knows to contain
materially false information concerning any fact material thereto; or conceals, for the purpose of misleading, information concerning any fact material thereto is considered a crime.
MAINE: 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, nes or denial of insurance benets.
MARYLAND: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benet or knowingly or willfully presents false information in an
Application for insurance is guilty of a crime and may be subject to nes and connement in prison.
OHIO: Any person who, with intent to defraud or knowing that he is facilitating a fraud against the Insurer, submits an Application or les a claim containing a false or deceptive
statement is guilty of insurance fraud.
OREGON: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benet or knowingly presents false information in an application for insurance may be
guilty of a crime and may be subject to nes and connement in prison.
TENNESSEE and WASHINGTON: 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, nes and/or denial of insurance benets.
If any answer to Questions 1 through 3 above are yes, attach full details.
New Applicants:
It is understood and agreed that any claim arising from any prior or pending litigation, written demand, employee grievances,
negotiated settlements or administrative proceeding shall be excluded from coverage. It is further understood and agreed that if
anyone has knowledge of any fact, circumstance or situation which could reasonably be expected to give rise to a future claim for any
coverage herein applied for, any such claim arising therefrom shall also be excluded from coverage.
Renewal Applicants:
It is understood and agreed that if the undersigned or any insured has knowledge of any fact, circumstance or situation which could
reasonably be expected to give rise to a future claim, then any increased limit of liability or coverage enhancement shall not apply to
such fact, circumstance, or situation. In addition, any increased limit of liability or coverage enhancement shall not apply to any claim,
fact, circumstance or situation for which the Insurer has already received notice.
800 Superior Avenue E., 21st Floor • Cleveland, OH 44114 • Phone: 866.327.6904 • Fax: 216.328.6251 • www.amtrust.com
Submit applications to: banksubmissions@amtrustgroup.com
APPL-BANC-EPL-01 0413 Page 3 of 3
MKT0807 4/15
Representation Statement
The undersigned declare that, to the best of their knowledge and belief, the statements in this Application, any prior Applications, any additional material submitted, and any publicly
available information published or led by or with a recognized source, agency or institution regarding business information for the Applicant for the 3 years prior to the Bond/
Policy’s inception [hereinafter called “Application”] are true, accurate and complete, and that reasonable efforts have been made to obtain sufcient information from each and every
individual or entity proposed for this insurance. It is further agreed by the Applicant that the statements in this Application are their representations, they are material and that the
Bond/Policy is issued in reliance upon the truth of such representations.
The signing of this Application does not bind the undersigned to purchase the insurance and accepting this Application does not bind the Insurer to complete the insurance or
to issue any particular Bond/Policy. If a Bond/Policy is issued, it is understood and agreed that the Insurer relied upon this Application in issuing each such Bond/Policy and any
Endorsements thereto. The undersigned further agrees that if the statements in this Application change before the effective date of any proposed Bond/Policy, which would render
this Application inaccurate or incomplete, notice of such change will be reported in writing to the Insurer immediately.
Chief Executive Ofcer, President or Chairman of the Board:
Print Name: _________________________________________________ Signature: ____________________________________________
Title: _______________________________________________________ Date: ________________________________________________
Chief Financial Ofcer or Equivalent Ofcer:
Print Name: _________________________________________________ Signature: ____________________________________________
Title: _______________________________________________________ Date: ________________________________________________
A BOND/POLICY CANNOT BE ISSUED UNLESS THE APPLICATION IS SIGNED AND DATED BY TWO INDIVIDUALS
Agent Name: ________________________________________________ License Number: ______________________________________
Agent Signature: _____________________________________________
Please provide the following information with your submission:
• Current Declarations Page from the Applicant’s Financial Institution Bond, D&O Policy, Bankers Professional Liability Policy,
Trust Errors & Omissions Policy, Employment Practices Liability Policy and/or Kidnap & Ransom Policy, if such bond/policies
are not currently written by AmTrust North America.
• Most recent Annual Report or audited nancial statements. If not applicable, attach a copy of the most recent Directors’
Examination Report.
• Management Letter and Applicant’s responses to any recommendations made therein.
• If applicable, most recent Form 10-K, 10-Q and any other Registration Statement led with the SEC within the past 12 months.
Submit Application to:
banksubmissions@amtrustgroup.com
AmTrust North America
Attention: Financial Institution Division
800 Superior Avenue E., 21st Floor • Cleveland, OH, 44114
Phone: 866.327.6904 • Fax: 216.328.6251
www.amtrustnorthamerica/nancial-institutions.com
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EPL FI Application

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Completed 2 July 2020

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