Fillable Employment Practices Liability Application - Employment_Practices_Application

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Employment Practices Liability Application - Employment_Practices_Application

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Page1of10



EMPLOYMENTPRACTICESLIABILITYAPPLICATION



1. Legalnameofthebusinesswhoistheprimaryapplicantandwillbethefirstnamedinsuredlistedonthepolicy:



2. Pleaselistallotherbusiness/dbanamesforwhichyouareseekingcoverageunderthispolicy:  



3. Corporation  Individual Partnership Municipality ForProfit JointVenture

Other:   

4. Pleaselistanynamesofotherentitiesthatyouownormanageorthatyoudobusinessunder(suchentitiesarenot

requestingcoverageunderthispolicy):



5. Primarylocationaddress:

6. Countyofprimarylocation:Datebusinessoriginallyestablished:    

7. Totalnumberofbranches?  Listalladdressesforadditionalbranches:



8. Whatisyourweb‐siteaddress?www.

9. Whatisyourphonenumber?

10. Hasthenameorownershipoftheentitychangedorhasanyotherbusinessbeenpurchased, Yes No 

mergedorconsolidatedwiththeentitywithinthelast5years? 

11. Doesanyentityownorcontrolyourbusinessordoesyourbusinessownorcontrolanyentity? Yes

No 

12. Duringthepastfiveyears,hasyournamebeenchangedorhasanyotherbusinesspurchased, Yes

No 

mergedorconsolidatedwithyou? 

Forquestions9‐11,pleasefullyexplainany“yes”response,includingthenames,dates,andrevenueimpactinvolved:





13. Pleaselistanyassociationsofwhichyouareamember:





1. PleasedescribethenatureoftheApplicant’sbusiness(typeofproductorservicesprovided):  





2. NumberofEmployees:FullTime:PartTime:



3. SalaryRangesNumberoffull  Numberofpart

(includingbonuses,dividendsandcommissions) timeemployees  timeemployees



$50,000orless:

$50,001to$100,000:

$100,001andover:

 TOTAL:  



GENERALINFORMATION

EMPLOYEES(includingSubsidiaryemployeeinformationonaseparatesheet)

KinsaleInsuranceCompany

P.O.Box17008

Richmond,VA23226

(804)289‐1300

www.kinsaleins.com

Page2of10



4. Ifyouhavemultiplelocations,pleaselistemployeesbystate:



tate:

tate:

Full‐Time  

Part‐Time  



5. DoestheApplicantuseseasonalortemporaryemployees? Yes

No 

Ifso,whenandhowmany?   

Aretheseemployeesincludedin#4above? Yes No 



6. 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#4above? Yes No 



7. DoestheApplicantuseindependentcontractors? Yes

No 

IfYes,howmanyworksolelyfortheApplicant?   



8. Howmanyemployeesarecoveredbycollectivebargainingorotherunionagreements?   



9. Inthepast12months,howmanyofficershaveleftyouremploy?   

Oftheabove,howmanywereterminated?   



10. Inthepast12months,howmanyotheremployeeshaveleftyouremploy?   

Oftheabove,howmanywereterminated?   



1. Pleaseanswerthefollowingfour(4)questionsfortheApplicantslistedin#1and#2oftheGeneralInformationSection,

includingitssubsidiaries,forthemostrecentfiscalyearend:

a. WhataretheApplicant’stotalassets?

b. WhataretheApplicant’stotalgrossrevenues?

c. DoestheApplicantcurrentlyhave: NetIncome orNetLoss Amount$

d. DoestheApplicantcurrentlyhave:PositiveCashflow orNegativeCashflow Amount$



2. Hasanauditorintheprevioustwo(2)fiscalyearsrecommendeda“goingconcern”opinion Yes

No 

 ofthefinancialinformationfortheApplicant?(IfYes,pleaseprovidedetailsonaseparatesheet.)



3. Areyou: PubliclyHeld?

IfYes,pleaseprovidestocksymbol

PrivatelyHeld? 

Non‐Profit?



Other?

Pleaseexplain.



1. Inthepasttwelve(12)months,hasyourtotalnumberofemployeesdecreasedbymore Yes

No 

thantenpercent(10)orfive(5)employees,whicheverisgreater,throughanyreduction

inforce,systematiclay‐off,closureofanydivision,officeorfacilitythatyouownoroperate

orforanyotherreason?(IfYes,pleasecompletetheReductionInForcesupplement.)



FINANCIALANDOPERATINGINFORMATION

EMPLOYMENTPRACTICES

Page3of10



2. Inthenexttwelve(12)months,doyouanticipatethetotalnumberofyouremployees Yes No 

todecreasebymorethantenpercent(10%)orfive(5)employees,whicheverisgreater,

throughanyreductioninforce,systematiclay‐off,closureofanydivision,officeorfacility

thatyouownoroperateorforanyotherreason?(IfYes,pleasecompletetheReduction

InForcesupplement.)



3. Ifduringthenext12months,circumstancesofwhichareyoucurrentlyunawaremakeit Yes No 

necessaryforyoutodecreasethenumberofyouremployeesbytenpercent(10%)orfive(5)

employees,whicheverisgreat,throughtheimplementationofanyreductioninforce,

systematiclayoff,closureofanydivision,officeorfacilitythatyouownoroperateorforany

otherreason(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ifqualifiedandexperiencedinthepracticeoflaborand

employmentlaw)asrespectstheimplementationofsuchreduction,lay‐offorclosure?

(IfNo,pleaseexplainonaseparatesheet.)



4. DoestheApplicantanticipateanymerger,acquisition,oradditionofanyoperationsthat Yes

No 

wouldcompriseatwenty‐fivepercent(25%)orten(10)employees,whicheverisgreater,

increaseoverthecurrentnumberofemployees?(IfYes,pleaseprovidefulldetailsona

separatesheet.)



5. Hasanyinsurerevercancelledornon‐renewedtheApplicantoritspredecessorforthis Yes

No 

typeofcoverage?(IfYes,pleaseprovidedetailsonaseparatesheet.)



1. DoestheApplicanthavewrittenemploymentagreementswithallofficers? Yes

No 

2. HavetheApplicant’smanagersand/orsupervisorsattendedtrainingandeducationprograms/ Yes

No 

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?   

3. DoestheApplicanthaveitsemploymentpolicies/proceduresreviewedbylabororemployment Yes No 

counsel?

IfYes,identifythefirmanddateoflastreview:   

4. DoestheApplicanthaveaHumanResourcesorPersonnelDepartment? Yes No 

IfNo,whohandlesthisfunction?   

5. 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upforitsreceipt? Yes

No 

IfYes,doesitexpresslystatethatitisnotacontractandthatemploymentis“atwill”? Yes

No 

6. DoestheApplicanthavewrittenproceduresforhandlingemployeecomplaintsofdiscrimination Yes

No 

and/orsexualharassment?

7. DoestheApplicantrequireallterminationstobereviewedby:

 Thepersoninchargeofhumanresources? Yes

No 

 Outsidecounsel? Yes

No 

8. DoestheApplicantmaintainapersonnelfileforeachemployee? Yes

No 



HUMANRESOURCES

Page4of10



1. Estimatednumberofemployeeswithcustomer/clientcontact:



2. Pleasedescribethefrequencyandnatureofcustomer/clientinteractions.





3. HastheApplicantoritspredecessorseverreceivedacomplaint,formalorinformal,froma Yes

No 

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.)



4. DoestheApplicantconductstafftrainingonclientandcustomerrelationsissuessuchas

 Yes No 

avoidingdiscriminatorybehavior?



5. Arethereproceduresforreportinganddealingwithcomplaintsbycustomers/clients? Yes

No 



6. IstheApplicantincompliancewithTitleIIIoftheAmericanswithDisabilitiesAct Yes

No 

(buildingandpremisesrequirements)?



1. Afterinquirywitheachpersonasappropriate,inthelastfive(5)years,doesanyonehaveany Yes

No 

 otherMaterialFactstodisclose?(IfYes,pleaseprovidesuchMaterialFactsonaseparatesheet.)



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oftheinformationrequestedinthisproposalismaterial.



1. Provideyourfirm’srecentEmploymentPracticesLiabilityinsurancehistorybelow(includingcoverageaspartofaD&O

orotherinsurancepolicy):



 

InsuranceCompany

LimitsPerClaim/

Aggregate Deductible

PolicyPeriod

(Month/Day/Year)

Annual

Premium

CurrentYear   

PreviousYear1   

PreviousYear2   

PreviousYear3   

PreviousYear4   



2. Ifyouarecurrentlyinsuredforemploymentpracticesliabilitycoverage,whatisyourpolicy’sretroactivedate?

(month/date/year)?____/_____/______Ifthereisnoretroactivedate,pleasecheckhere.



THIRDPARTYINFORMATION

OTHERMATERIALINFORMATION

INSURANCEANDLOSSHISTORY

Page5of10



Ifrequestingprioractscoverageyouwillbeaskeduponbindingcoveragetoprovideacopyofyourcurrentinsurance

declarationpagedocumentingtheexpiringretroactivedateandlimits.Prioractscoveragemaynotbeavailableifthe

dateofyourcurrentretroactivecoverageisdifferentfromwhatwehavequoted

orifthereisanygapbetween

effectivedates.



3. Areyoubeingcanceledornon‐renewedbyyourcurrentemploymentpracticesliabilitycarrier? Yes

No 

IfYes,pleaseexplainwhy:



4. RequestedLimits:

$100,000/$300,000 $250,000/$250,000 $500,000/$500,000 $1,000,000/$1,000,000



Other$/$



RequestedDeductible(PerClaim):

$5,000$10,000 $25,000 Other



5. Afterinquirywitheachpersonasappropriate,inthelastfive(5)years,hasanywrongfultermination, Yes

No 

discrimination,sexualharassmentoranyotherwrongfulemploymentpracticesliabilityclaim

orsuit,includingthirdpartyclaims,everbeenmadeagainsttheFirmoranypredecessorfirmor

anycurrentorformermemberoftheFirmorpredecessorfirm? 



 If“Yes,”howmany?PleasecompleteaseparateSupplementalClaim

Form

 foreachclaimorsuitandincludeacurrentlyvaluedlossrunforeachclaim.



6. Afterinquirywitheachpersonasappropriate,doyou,oranyofyourpartners,officers, Yes

No 

directors,oremployeesknowofanycircumstances,acts,errors,omissions,oranyallegations

orcontentionsofanyincidentthatcouldresultinanunemploymentrelatedclaim,including

thirdpartyclaims? 



If“Yes,”howmany?If“Yes,”pleasecompleteaseparateSupplemental

ClaimFormforeachpotentialclaimandprovideasmuchdetailaspossible.



7. OfthetotalnumberofEEOC/stateagencychargesfiledagainstanyApplicantoverthelastfiveyears,indicatethe

numberofprimaryallegationsasfollows:



1) LocationNo. 2) Racial

Discrimination

3) Age

Discrimination

4) Religious

Discrimination

5) OtherEthic

Discrimination

6) EqualPay

ActViolation

7) Other

Gender

Discrimination

8) Violationof

Am.With

Disabl.Act

  



8. Withrespecttolitigatedcases(includingwrongfulterminationsuitsunderstatelawotherthanantidiscriminationlaw)

andEEOC/stateagencychargesoverthelastfiveyearsforwhichanysettlementwasormaybepaid,pleaseprovidethe

followinginformation,whichmustbecurrentlyvalued:



Date

Occurrence

Claimant Allegation DamagesPaid DamagesReserved LegalExpenses

Paid

LegalExpenses

Reserved

 



Page6of10



FRAUDWARNING



NOTICETO ALABAMA,ALASKA, ARIZONA,ARKANSAS,CALIFORNIA,CONNECTICUT,DELAWARE,GEORGIA, IDAHO,ILLINOIS, INDIANA,IOWA, KANSAS,

MARYLAND, MASSACHUSETTS, MICHIGAN, MINNESOTA, MISSISSIPPI, MISSOURI, MONTANA, NEBRASKA, NEVADA, NEW HAMPSHIRE, NORTH

CAROLINA,NORTHDAKOTA,OREGON,RHODEISLAND,SOUTHCAROLINA,SOUTHDAKOTA,TEXAS,UTAH,VERMONT,WASHINGTON,WEST VIRGINIA,

WISCONSIN, AND WYOMING APPLICANTS:In some

 states, 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, for the purpose of misleading, conceals

informationconcerninganyfactmaterialthereto,maycommitafraudulentinsuranceactwhich

isacrimeinmanystates.



NOTICETOCOLORADOAPPLICANTS: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 policyholderor

claimantforthepurposeofdefraudi ng orattemptingtodefraudthepolicyholderorclaimi ngwithregardtoasettlementorawardpayableforinsurance

proceedsshallbereported

totheColoradoDivisionofInsurancewithintheDepartmentofRegulatoryAgencies.



NOTICETODISTRICTOFCOLUMBIA APPLICANTS:  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.



NOTICETO FLORIDAAPPLICANTS:Anyperson whoknowinglyand withintentto injure,defraud ordeceiveanyinsurancecompany filesa statementof

claimcontaininganyfalse,incompleteor

misleadinginformationisguiltyofafelonyofthethirddegree.



NOTICETOHAWAIIAPPLICANTS:Foryourprotection,Hawaiilawrequiresyoutobeinformedthatpresentingafraudulentclaimforpaymentofalossor

benefitisacrimepunishablebyfinesorimprisonment,orboth.



NOTICETOKENTUCKY

APPLICANTS: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.



NOTICE

TO LOUISIANA APPLICANTS: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isguiltyofacrimeandmaybesubjecttofinesandconfinementinprison.



NOTICETOMAINEAPPLICANTS:

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denialofinsurancebenefits.



NOTICETONEWJERSEYAPPLICANTS:Anypersonwhoincludesanyfalseormisleading informationonanapplication

foraninsurancepolicyissubjectto

criminalandcivilpenalties.



NOTICE TO NEW MEXICO APPLICANTS: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isguiltyofacrimeandmay

besubjecttocivilfinesandcriminalpenalties.



NOTICETONEWYORKAPPLICANTS:Anypersonwhoknowinglyandwithintenttodefraudan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$5,000andthestatedvalue

oftheclaimforeachsuchviolation.



NOTICE TO OHIO APPLICANTS:Any person who, with intent to defraud or

 knowing that he/she 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.



NOTICETOOKLAHOMAAPPLICANTS:WARNING:Anypersonwhoknowingly,andwithintenttoinjure,defraudordeceiveanyinsurer,makesaany

claim

fortheproceedsofaninsurancepolicycontaininganyfalse,incompleteormisleadinginformationisguiltyofafelony.



NOTICE TO PENNSYLVANIA APPLICANTS:Any person who knowingly and with intent to defraud any insurance company, or other pe rson, files an

application for insurance or statement of a 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thepersontocriminalandcivilpenalties.



NOTICE TO TENNESSEE APPLICANTS: 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.



NOTICETOVIRGINIAAPPLICANTS: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.





Page7of10



TheApplicantacknowledgesthattheanswersprovidedhereinarebasedonareasonableinquiryand/orinvestigation.TheApplicantwarrantsthatthe

above statements and particulars together with any attached or appended documents are true and complete and do not misrepresent, misstate or

omitanymaterialfacts.



TheApplicantagreesto

notifyusofanymaterialchangesintheanswerstothequestionsonthisquestionnairewhichmayarisepriortotheeffective

dateofanypolicyissuedpursuanttothisquestionnaireandtheApplicantunderstandsthatanyoutstandingquotationsmaybemodifiedorwithdrawn

baseduponsuchchangesatoursole

discretion.



Completion ofthisformdoesnotbindcoverage. Applicant’sacceptanceofthe company’squotationisrequired prior tobinding coverageandpolicy

issuance.



All written statements and materi als  furnished to the company in conjunction with this application are hereby incorporated by reference into this

applicationandmadea

partofthisapplication.



Applicant:   Title:

 (MustbesignedbyaDirectorofHumanResourcesorother

 Principal,Partner,orOfficeroftheFirm)



Applicant’sSignature:   Date: 



Agent/BrokerName:  



 

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

EMPLOYMENT

PRACTICESLIABILITYCLAIMAPPLICATION



  ThisformistobecompletedwhentheApplicanthasbeeninvolvedinanyclaimorisawareofanincidentwhich

 maygiverisetoaclaim.COMPLETEONEFORMFOREACHCLAIMORINCIDENT.

  Ifspaceisinsufficienttoansweranyquestionsfully,attacha

separatesheet.

  Inlieuofattachingsuitpapers,pleaseprovideacompletenarrativedescriptionoftheallegationsinvolved



1. FullNameofApplicant:



2. FullNameofIndividual(s)orentityinvolvedintheclaim:



3. Additionaldefendants



4. FullNameofClaimant:



5. a. IstheClaimantstillyouremployee(orclientifaThirdPartyClaim)afterbringingtheclaim? Yes

No 

b. Areotherwitnesses/involvedpartiesstillemployed?  Yes

No 



6. Dateofclaim:DatereportedtoInsuranceCompany:



7. Whatisthestatusoftheclaim? Closed/Settled

 Open/Pending  Incident/Circumstance 



8. IFCLOSED:

Totalpaidincludingdeductible(s)?Responsessuchas“unknown”or“unavailable”areinsufficient.

 Defensecosts Loss/compensatorydamages

Paidbyyou‐outofpocket $ $

InsuranceCompany $ $



 DateResolved:_____/_____/_____ Trial

  OutofCourt 



9. IFPENDING:

(a) Claimant’ssettlementdemand?$ _____Defendant’ssettlementoffer(ifany):$

(b) Insurer’sreserveamounts?Loss$Defense$

(d) Whatisyourbestestimateofthelikelysettlementamountforthismatter?$

(e) Whatisyourbestestimateofthedatewhenyouexpectthisclaimtoberesolved?

Note:Answering“unknown”or“unavailable”totheabovequestionsisaninsufficientresponse.



10. Theclaiminvolves/involvedthefollowinglawsorissues(pleasecheckallthatapply):



AffirmativeAction

 FalseImprisonment Slander 

BodilyInjury   GoodFaithandFairDealing ThirdParty/Non‐EmployeeClaim

(Ifso,pleaseexplain.)

________________________________

BreachofWrittenContract  ImpliedContract WhistleBlowerRetaliation

APPLICANT’SINFORMATION

KinsaleInsuranceCompany

P.O.Box17008

Richmond,VA23226

(804)289‐1300

www.kinsaleins.com

Page9of10



Discrimination   

(Type:___________________________

________________________________

________________________________)

InvasionofPrivacy

WrongfulTermination

EmotionalDistress  Libel/Defamation OtherIssues:____________________

_________________________________

_________________________________

EqualPayAct(EPA) Retaliation

FLSA(FairLaborStandards) 

WageandHour

Retaliation(Type):______________

_______________________________

FMLA  SexualHarassment



11. Name(s)ofInsurer(s)respondingtothisclaimorincident

PolicyNumber:

LimitsofLiability:Deductible:



12. Providenarrativedescriptionofsuit,claimorincident,includingtheallegationsinvolved,thepotentialsizeofinjury

andyourresponse:





13. Explainwhataction(s)havebeentakentopreventreoccurrenceofasimilarclaim:  ______ 

_____



Ideclarethattheinformationsubmittedhereinistruetothebestofmyknowledgeandbecomesapartofmy

EmploymentPracticesLiabilityApplication.Iunderstandthatanincorrectorincompletestatementcouldvoid

myprotection.



 

 SignatureofApplicant/Title/Date (MustbesignedbyaPrincipal,PartnerorOfficeroftheFirm)



FRAUDWARNING



NOTICETO ALABAMA,ALASKA, ARIZONA,ARKANSAS,CALIFORNIA,CONNECTICUT,DELAWARE,GEORGIA, IDAHO,ILLINOIS, INDIANA,IOWA, KANSAS,

MARYLAND, MASSACHUSETTS, MICHIGAN, MINNESOTA, MISSISSIPPI, MISSOURI, MONTANA, NEBRASKA, NEVADA, NEW HAMPSHIRE, NORTH

CAROLINA,NORTHDAKOTA,OREGON,RHODEISLAND,SOUTHCAROLINA,SOUTHDAKOTA,TEXAS,UTAH,VERMONT,WASHINGTON,WEST VIRGINIA,

WISCONSIN, AND WYOMING APPLICANTS:In

 some states, any person who knowingly, and with intent to defraud any insurance company or other

informationconcerninganyfactmaterialthereto,maycommitafraudulentinsuranceact

whichisacrimeinmanystates.



NOTICETOCOLORADOAPPLICANTS: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 policyholderor

proceedsshallbe

reportedtotheColoradoDivisionofInsurancewithintheDepartmentofRegulatoryAgencies.



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.



claimcontaininganyfalse,incomplete

ormisleadinginformationisguiltyofafelonyofthethirddegree.



NOTICETOHAWAIIAPPLICANTS:Foryourprotection,Hawaiilawrequiresyoutobeinformedthatpresentingafraudulentclaimforpaymentofalossor

benefitisacrimepunishablebyfinesorimprisonment,orboth.



NOTICE

TOKENTUCKYAPPLICANTS:Anypersonwhoknowinglyandwithintenttodefraudanyinsurancecompanyorotherpersonfilesanapplicationfor

commitsafraudulentinsuranceact,whichisacrime.



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Page10of10



NOTICE TO LOUISIANA APPLICANTS: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isguiltyofacrimeandmaybesubjecttofinesandconfinementinprison.



NOTICETOMAINEAPPLICANTS

: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denialofinsurancebenefits.



NOTICETONEWJERSEYAPPLICANTS:Anypersonwhoincludesanyfalseormisleading informationonan

applicationforaninsurancepolicyissubjectto

criminalandcivilpenalties.



presentsfalseinformationinanapplicationforinsuranceisguiltyofacrimeand

maybesubjecttocivilfinesandcriminalpenalties.



NOTICETONEWYORKAPPLICANTS:Anypersonwhoknowinglyandwithintenttodefraudan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

oftheclaimforeachsuchviolation.



NOTICE TO OHIO APPLICANTS:Any person who, with intent to

 defraud or knowing that he/she 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.



NOTICETOOKLAHOMAAPPLICANTS:WARNING:Anypersonwhoknowingly,andwithintenttoinjure,defraudordeceiveanyinsurer,makes

aanyclaim

fortheproceedsofaninsurancepolicycontaininganyfalse,incompleteormisleadinginformationisguiltyofafelony.

application for insurance or statement of a

 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thepersontocriminalandcivilpenalties.



NOTICE TO TENNESSEE APPLICANTS: It is a crime to knowingly provide false, incomplete

 or misleading information to an insurance compan y for the

purposeofdefraudingthecompany.Penaltiesincludeimprisonment,finesanddenialofinsurancebenefits.



NOTICETOVIRGINIAAPPLICANTS: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.



TheApplicantacknowledgesthattheanswersprovidedhereinarebasedonareasonableinquiryand/orinvestigation.TheApplicantwarrantsthatthe

above statements and particulars together with any attached or appended documents are true and complete and do not misrepresent, misstate

or

omitanymaterialfacts.



TheApplicantagreestonotifyusofanymaterialchangesintheanswerstothequestionsonthisquestionnairewhichmayarisepriortotheeffective

dateofanypolicyissuedpursuanttothisquestionnaireandtheApplicantunderstandsthatanyoutstandingquotationsmaybemodified

orwithdrawn

baseduponsuchchangesatoursolediscretion.



issuance.



All written statements and materi als  furnished to the company in conjunction with this application are hereby incorporated

 by reference into this

applicationandmadeapartofthisapplication.



Applicant:______________________________________ Title:  

 (MustbesignedbyaPrincipal,Partner,orOfficeroftheFirm)



Applicant’sSignature:_____________________________ Date:  



Agent/BrokerName:    



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Employment Practices Liability Application - Employment_Practices_Application

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Completed 2 July 2020

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