Fillable Employment-Practices-Liability-Claim-Application - Employment Practices Liability Claim Application

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Employment-Practices-Liability-Claim-Application - Employment Practices Liability Claim Application

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Page1of3



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.)

_________________________________

APPLICANT’SINFORMATION

KinsaleInsuranceCompany

P.O.Box17008

Richmond,VA23226

(804)289‐1300

www.kinsaleins.com

Page2of3



BreachofWrittenContract

 ImpliedContract WhistleBlowerRetaliation

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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,in complete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defrauding or attempting to defraudthepolicyholderorclaiming  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clai mforpaymentofalossor

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



click to sign

signature

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Page3of3



NOTICETOKENTU CKY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 mat erial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 APPLICA N TS: 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 person, 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.



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 materials 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-Claim-Application - Employment Practices Liability Claim Application

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Completed 2 July 2020

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