Fillable Employment Practices Liability Application All States (Special Risks)

Fill Online, Printable, Fillable, Blank Employment Practices Liability Application All States (Special Risks) Form

Use Fill to complete blank online SPECIAL RISKS pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Employment Practices Liability Application All States (Special Risks)

On average this form takes 19 minutes to complete

The Employment Practices Liability Application All States (Special Risks) form is 3 pages long and contains:

  • 2 signatures
  • 10 check-boxes
  • 62 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your Special Risks forms online.

BROWSE SPECIAL RISKS FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
page 1 of 3
CARRIER:
EPL 5/14 – USLI
Employment Practices Liability Application – All States
THIS COVERAGE IS LIMITED TO CLAIMS FIRST MADE AND REPORTED TO THE COMPANY DURING THE POLICY PERIOD AS STATED IN THE DECLARATIONS OR ANY AP-
PLICABLE EXTENDED REPORTING PERIOD. DEFENSE COSTS SHALL BE APPLIED AGAINST THE RETENTION. PLEASE READ YOUR POLICY CAREFULLY.
New York Disclosure Notice: Under EPL 133 NY and EPL162 NY, if made part of your policy, or Section IV Exclusions C, the limits of liability available under this
policy may be completely exhausted by the payment of defense costs.
Applicant may qualify for an INSTANT QUOTE by completing Section I below. Section II and III answers will be required prior to binding and are subject to
underwriting approval.
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 the application and submit details in a
USLI claim supplement.
Primary Applicant’s name
(See #4 to add subsidiary[ies]/affiliate[s])
: ________________________________________________________________
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(ies)/affiliate(s) covered? If “Yes,” include employees in employee q Yes q No
count above and provide:
a) Name of subsidiary(ies)/affiliate(s)
b) Is the subsidiary(ies)/affiliate(s) at least 50% owned by the applicant? q Yes q No
c) Does the subsidiary(ies)/affiliate(s) fall within the same class of business as the applicant? q Yes q No
5. Expiring policy: Retroactive date _________ Carrier _________________ Limits __________ Retention ________ Premium _________
(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, 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 related, 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)
page 2 of 3
IV. ADDITIONAL APPLICANT INFORMATION
Applicant’s mailing address: ______________________________________________________________________________________
City: _______________________________________________ State: ___________________ Zip: _____________________
FRAUD STATEMENTS
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.
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: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application
containing any false, incomplete, or misleading information is guilty of a felony of the third degree.
Florida Notice: (Applies only if policy is non-admitted) 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.
Florida and Illinois Punitive Damages 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.
Kansas Fraud Statement: 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 benefit pursuant to an insurance policy
for commercial or personal 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 may be guilty of a crime and may be subject to fines and confinement in prison.
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 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. A binder may not be withdrawn but a prospective notice of cancellation
may be sent and coverage denied for fraud or material misrepresentation in obtaining coverage. A policy may not be unilaterally rescinded or voided.
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. A binder may not be withdrawn but
a prospective notice of cancellation may be sent and coverage denied for fraud or material misrepresentation in obtaining coverage. A policy may not be
unilaterally rescinded or voided.
Maryland Fraud Statement: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or
willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
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.
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.
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
EPL 5/14 – USLI
III. WRITTEN EMPLOYMENT GUIDELINES
q Applicant currently has a written e-mail/internet policy in place
OR
q Applicant agrees to implement a written email/internet policy within 60 days of the effective date of coverage OR
q Applicant does not have a written email/internet policy in place and will not implement such policy.
The written employment policies below are required to obtain coverage with USLI. By checking the boxes below and signing this application, the
applicant agrees they either have or will implement and maintain the policies below within sixty (60) days of the effective date of coverage
q Applicant currently has a written anti-discrimination policy in place OR
q Applicant agrees to implement a written anti-discrimination policy within 60 days of the effective date of coverage OR
q Applicant does not have a written anti-discrimination policy in place and will not implement such policy.
q Applicant currently has a written anti-harassment policy in place
OR
q Applicant agrees to implement a written anti-harassment policy within 60 days of the effective date of coverage OR
q Applicant does not have a written anti-harassment policy in place and will not implement such policy.
page 3 of 3
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.
North Dakota Fraud Statement: Notice to North Dakota applicants – Any person who knowingly and with the intent to defraud and 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.
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.
Ohio Representation Statement: By acceptance of this policy, the Insured agrees the statements in the application (new or renewal) submitted to the company
are true and correct. It is understood and agreed that the statements made in the insurance applications are incorporated into, and shall form part of, this policy.
the insured understands and agrees that any material misrepresentation or omission on this application will act to render any contract
of insurance null and without effect or provide the company the right to rescind it.
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.
Oregon Fraud Statement: Notice to Oregon applicants: Any person who, with intent to defraud or knowing that he is facilitation a fraud against an insurer,
submits an application or files a claim containing a false or deceptive statement may be guilty of insurance fraud.
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 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.
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
Utah 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.
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.
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.
Virginia Fraud Statement: Any person who knowingly and with intent to defraud an insurer, submits an Application for insurance or files a claim containing a
false or deceptive statement is guilty of insurance fraud.
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.
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 is guilty of a crime and may be subject to fines and confinement in prison.
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.
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:____________________________________
President, Chairperson of the Board, Managing Member, or Executive Director
Date:_____________________________________________________
EPL 5/14 – USLI
click to sign
signature
click to edit
click to sign
signature
click to edit
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Employment Practices Liability Application All States (Special Risks)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 9 July 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document