Fillable Employment Practices Renewal Application 310002-P (4/97) page 1 of 11

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Employment Practices Renewal Application 310002-P (4/97) page 1 of 11

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The Employment Practices Renewal Application 310002-P (4/97) page 1 of 11 form is 6 pages long and contains:

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  • 46 check-boxes
  • 109 other fields

Country of origin: US
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Page 1 of 6
EMPLOYMENT PRACTICES LIABILITY RENEWAL APPLICATION
1. Current Kinsale Policy Number:
2. Legal name of the business who is the primary applicant and will be the first named insured listed on the policy:
3. Please list all other business/dba names for which you are seeking coverage under this policy:
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:
7. Total number of branches? List all addresses for additional branches:
8. 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 12 months or are any such changes
contemplated for the next 12 months?
9. Does any entity own or control your business or does your business own or control any entity? Yes No
1. Please describe the nature of the Applicant’s business (type of product or services provided):
2. Number of Employees Currently: Full Time: Part Time:
Number of Employees Projected 12 Months from today: 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:
4. If you have multiple locations, please list employees by state:
State:
State:
State:
State:
State:
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
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 6
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
Of the above, how many were terminated?
have left your employ?
10. In the past 12 months, how many
other employees
Of the above, how many were terminated?
have left your employ?
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 12 months 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.)
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
FINANCIAL AND OPERATING INFORMATION
EMPLOYMENT PRACTICES
Page 3 of 6
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.)
1. Please provide a summary of any significant changes to your Human Resources policies or procedures made during
the past 12 months or contemplated for the next 12 months.
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 received a complaint, formal or informal, from a non- Yes No
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 in the past 12 months?
(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 12 months, 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.
HUMAN RESOURCES
THIRD PARTY INFORMATION
OTHER MATERIAL INFORMATION
Page 4 of 6
1. After inquiry with each person as appropriate, in the last 12 months, has any wrongful termination Yes No
discrimination, sexual harassment claims 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.
2. 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 details as possible.
3. Of the total number of EEOC/state agency charges filed against any Applicant over the last 12 months, indicate the
number of primary allegations as follows:
1) Location No.
2) Racial
Discrimination
3) Age
Discrimination
4) Religious
Discrimination
5) Other Ethic
Discrimination
Act Violation
7) Other
Gender
Discrimination
8) Violation of
Am. With
Disabl. Act
4. With respect to litigated cases (including wrongful termination suits under state law other than antidiscrimination law)
and EEOC/state agency charges over the last 12 months 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
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 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.
INSURANCE AND LOSS HISTORY
Page 5 of 6
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 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.
Page 6 of 6
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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Completed 2 July 2020

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