12. Does the Company have a Human Resources Department? Yes No
If “No”, describe how human resource functions are administered in an attachment to this Proposal Form.
13. Does the Company have a human resources manual? Yes No
If “Yes”, does this manual contain policies and procedures addressing the following areas:
(a) Compliance with the Americans with Disabilities Act; Yes No
(b) Compliance with Title VII of the Civil Rights Act of 1964 and the 1991 Civil Rights Act; Yes No
(c) Compliance with the Family Medical Leave Act; Yes No
(d) Prohibited discriminatory practices in hiring, promotion, and compensation; Yes No
(e) Employee performance evaluations; Yes No
(f) Employee disciplinary actions and discharge; Yes No
(g) Sexual harassment and the work environment; Yes No
(h) Employee grievance reporting and resolution processes. Yes No
If “No” to any of the above, please provide details in an attachment to this Proposal Form.
14. Do all managerial and supervisory personnel:
(a) have a copy of the human resources manual? Yes No
(b) receive training in the implementation of these policies and procedures? Yes No
If “No”, explain how human resources policies and procedures are communicated to managers
and supervisors in an attachment to this Proposal Form.
15. Are all employees provided with and required to acknowledge receipt of a handbook that addresses
the areas detailed in item 13. above? Yes No
If “No”, explain how human resources policies and procedures are communicated to employees
in an attachment to this Proposal Form.
16. Have there been during the last five years, or are there now pending, any employment related civil,
criminal, administrative or arbitration proceedings (including any proceeding initiated before the
Equal Employment Opportunity Commission) brought against:
(a) the Company or its Subsidiaries? Yes No
(b) any person proposed for this insurance in their capacity as either Director, Officer, or employee
of the Company or its Subsidiaries? Yes No
If “Yes” to either of the above, in an attachment to this Proposal Form, provide details including the
nature of the allegations, the date the proceeding was initiated, the current status, and loss
(including defense costs) incurred.
17. Have there been during the last five years, or are there now pending, criminal, administrative or arbitration
proceedings by any customer, client or other third party against the Company, its subsidiaries or any person
proposed for this insurance alleging discrimination, harassment or violations of civil rights based upon
discrimination or harassment? If “Yes”, provide details in an attachment to this Proposal Form. Yes No
IT IS AGREED THAT ANY CLAIM ARISING FROM ANY PRIOR OR PENDING PROCEEDING
DESCRIBED IN 16. OR 17. ABOVE IS EXCLUDED FROM THE PROPOSED COVERAGE.
18. Is the undersigned or any Director or Officer proposed for this insurance aware of any fact, circumstance
or situation involving the Company or its Subsidiaries which he or she has reason to believe might result
in any future Employment Practices Claim under the policy to which this Proposal Form will be attached? Yes No
If “Yes”, please provide details in an attachment to this Proposal Form.
IT IS AGREED THAT IF KNOWLEDGE OF ANY SUCH FACT, CIRCUMSTANCE OR SITUATION EXISTS,
ANY CLAIM SUBSEQUENTLY ARISING THEREFROM SHALL BE EXCLUDED FROM COVERAGE.
19. Current or prior Employment Practices Liability Insurance (stand-alone or incorporated into some other coverage):
Insurer Limit Retention Premium Policy Period
_________________ _________________ _________________ _____________ ______________
(a) has any claim been made or has any notice been given to any insurer? Not Applicable Yes No
(b) has any insurer cancelled or non-renewed the above coverage? Not Applicable Yes No
If “Yes” to any of the above, provide details in an attachment to this Proposal Form.
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