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PRIVATE COMPANY PROTECTION PLUS EMPLOYMENT PRACTICES LIABILITY INSURANCE (Philadelphia Insurance Companies)

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PRIVATE COMPANY PROTECTION PLUS
EMPLOYMENT PRACTICES LIABILITY INSURANCE
UNDERWRITTEN BY PHILADELPHIA INDEMNITY INSURANCE COMPANY OR TOKIO MARINE SPECIALTY
INSURANCE COMPANY
NOTICE: THIS POLICY IS WRITTEN ON A CLAIMS MADE BASIS AND COVERS ONLY THOSE CLAIMS
FIRST MADE DURING THE POLICY PERIOD AND REPORTED IN WRITING TO THE UNDERWRITER
PURSUANT TO THE TERMS HEREIN. THIS POLICY PROVIDES A LIMIT OF LIABILITY AVAILABLE TO PAY
JUDGMENTS OR SETTLEMENTS THAT SHALL BE REDUCED BY AMOUNTS INCURRED AS DEFENSE
COSTS. FURTHER NOTE THAT DEFENSE COSTS PAID SHALL BE APPLIED AGAINST THE RETENTION
AMOUNT.
INSTRUCTIONS
Whenever used in this Application the term Applicant shall mean the Named Corporation and its majority owned
Subsidiaries and their respective Employees.
SUBMISSION REQUIREMENTS
• Copies of the latest versions of the Applicant’s employee handbook and employment applications
• Applicant’s latest fiscal year end financial statement (CPA prepared), if the total number of employees
exceeds three hundred (300). Financial statements are required for all California submissions.
GENERAL INFORMATION
1. Name of Applicant:
2.
Website address: www.
Risk Management’s Phone:
Address:
Telephone:
Risk Management Contact:
Risk Management Email:
3. Standard Industrial Classification (SIC) Code:
Federal Employer Identification Number (FEIN):
4. State of incorporation: Date established:
Form of Incorporation (Inc., Ltd., LLC., etc.):
5. Please describe the nature of the Applicant’s operations:
6. Provide a list of all direct and indirect subsidiaries.
Name:
Percent Owned by the Applicant:
%
Name:
Percent Owned by the Applicant:
%
Type of Business:
Date created/acquired:
Type of Business:
Date created/acquired:
PI-PRD-New App (12/09)
Page 1 of 5
© 2017 Philadelphia Consolidated Holding Corp.
10/2017
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Name: Type of Busi
ness:
Percent Owned by the Applicant: % Date created/acquired:
EMPLOYMENT PRACTICES INFORMATION
7. Employment Practices Liability Insurance has been continuously in force since:
8. Please provide the following employee count information:
Currently One Year Ago
Total U.S. based employees:
Total Full Time:
Total Part Time:
Volunteers:
Temporary:
Leased:
Total Non U.S. based employees:
TOTAL SUM OF ABOVE:
Employees in the state of: CA: NJ: TX:
FL: NY:
9. Total number of current employees with annual compensation greater than $100,000:
10. How many employees have been terminated in the past 12 months?
Voluntary: Involuntary: Laid off:
11. Is any reduction of employees or change of status anticipated or being contemplated in the next
year? If yes, number estimated:
Yes No
Voluntary: Involuntary: Layoffs:
12. Does the Applicant anticipate any plant, facility, branch, office, or department closing,
consideration, reorganization or layoff within the next twenty-four (24) months? Yes No
If yes, provide details.
13.
Human Resource Policies and Procedures:
Does the Applicant:
have a standard employment application for all applicants? Yes No
have an employment handbook? Yes No
have an "At Will" provision in the employment application? Yes No
have a written policy with respect to sexual harassment? Yes No
have a written policy with respect to discrimination? Yes No
have written annual evaluations for employees? Yes No
Please provide an explanation by attachment for all No answers
.
14.
Third Party Policies and Procedures:
Does the Applicant:
a. have policies or procedures outlining employee conduct when dealing with customers,
clients, vendors, the general public or other third parties, including non-discrimination
and non-harassment statements?
Yes
No
b. have policies or procedures for responding to complaints of harassment, discrimination,
or civil rights violations from its customers, clients, vendors, the general public or other
third parties?
Yes
No
PI-PRD-New App (12/09)
Page 2 of 5
© 2017 Philadelphia Consolidated Holding Corp.
10/2017
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GENERAL SUMMARY
(The Applicant must complete this section)
15. Current Coverage
Employment
Practices
Coverage
Insurance Company
Limit of Liability
Deductible
Effective
Date
Premium
Currently
$ $ $
Prior Year
$ $ $
a. With respect to the above coverage, has any Underwriter refused, canceled or non-
renewed coverage? (Not Applicable in Missouri)
Yes
No
If yes, provide details by attachment.
b. With respect to the above coverage, has any Underwriter indicated an intent not to offer
renewal terms to the Applicant? (Not Applicable in Missouri)
Yes
No
If yes, provide details by attachment.
CLAIM / WARRANTY SECTION
16.
Has the Applicant for this insurance been involved in any of the following?
a. Any discriminatory practice violation or litigation? Yes No
b. Any disciplinary action by any regulatory agency or association, including the EEOC? Yes No
Please provide an explanation by attachment if questions 16a or 16b is answered yes.
17.
Has the Applicant given notice of claims, specific facts or circumstances which might give rise
to a claim under any prior policies providing similar insurance?
Yes
No
If yes, a Supplemental Claim form is required.
Note: This question is required if no previous Employment Practice Insurance
exists or a gap in coverage has occurred
.
18. No person applying for this coverage is aware of any facts or circumstances which he or she
has reason to presume might give rise to a future claim that would fall within the scope of any
of the proposed coverages for which the Applicant has applied, except:
None As noted below
Provide attachment if necessary.
Without prejudice to any
other rights and remedies of the Underwriter, any claim arising from any claims,
facts, circumstances or situations whether or not disclosed in questions 16a, 16b, 17 and 18 above is
excluded from the proposed insurance.
Material Change
If there are any material changes to the answers of this Application’s questions prior to the
policy inception date, the Applicant must notify the Underwriter in writing. Any outstanding
quotation may be modified or withdrawn.
PI-PRD-New App (12/09)
Page 3 of 5
© 2017 Philadelphia Consolidated Holding Corp.
10/2017
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FRAUD STATEMENT AND SIGNATURE SECTIONS
The Undersigned states that he/she is an authorized representative of the Applicant and declares to the best of his/her
knowledge and belief and after reasonable inquiry, that the statements set forth in this Application (and any attachments
submitted with this Application) are true and complete and may be relied upon by Company * in quoting and issuing the
policy. If any of the information in this Application changes prior to the effective date of the policy, the Applicant will notify
the Company of such changes and the Company may modify or withdraw the quote or binder.
The signing of this Application does not bind the Company to offer, or the Applicant to purchase the policy.
*Company refers collectively to Philadelphia Indemnity Insurance Company and Tokio Marine Specialty Insurance Company
.
FRAUD NOTICE STATEMENTS
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 AND SUBJECTS THAT PERSON TO
CRIMINAL AND CIVIL PENALTIES (IN OREGON, THE AFOREMENTIONED ACTIONS MAY CONSTITUTE A FRAUDULENT INSURANCE ACT WHICH MAY
BE A CRIME AND MAY SUBJECT THE PERSON TO PENALTIES). (IN NEW YORK, THE CIVIL PENALTY IS NOT TO EXCEED FIVE THOUSAND DOLLARS
($5,000) AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION). (NOT APPLICABLE IN AL, AR, AZ, CO, DC, FL, KS, LA, ME, MD, MN,
NM, OK, PA, RI, TN, VA, VT, WA AND WV).
APPLICABLE IN AL, AR, AZ, DC, LA, MD, NM, RI AND WV: ANY PERSON WHO KNOWINGLY (OR WILLFULLY IN MD) PRESENTS A FALSE OR
FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR WHO KNOWINGLY (OR WILLFULLY IN MD) PRESENTS FALSE INFORMATION IN AN
APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES OR CONFINEMENT IN PRISON.
APPLICABLE IN COLORADO: 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.
APPLICABLE IN FLORIDA AND OKLAHOMA: 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 (IN FL, A PERSON IS GUILTY OF A FELONY OF THE THIRD DEGREE).
APPLICABLE IN KANSAS: AN ACT COMMITTED BY 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, ELECTRONIC, ELECTRONIC IMPULSE, FACSIMILE, MAGNETIC, ORAL, OR TELEPHONIC COMMUNICATION
OR 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.
APPLICABLE IN KENTUCKY: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSONS
FILES AN APPLICATION FOR INSURANCE CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS, FOR THE PURPOSE OF
MISLEADING, INFORMATION CONCERNING ANY MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME.
APPLICABLE IN MAINE, TENNESSEE, VIRGINIA AND WASHINGTON: 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.
APPLICABLE IN PENNSYLVANIA: 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.
APPLICABLE IN NEW YORK: 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 BE SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE STATE VALUE OF THE CLAIM FOR EACH
SUCH VIOLATION.
NAME (PLEASE PRINT/TYPE) TITLE
(MUST BE SIGNED BY THE PRESIDENT, CHAIRMAN, CEO OR EXECUTIVE
DIRECTOR)
______________
______________________________________
SIGNATURE DATE
SECTION TO BE COMPLETED BY THE PRODUCER/BROKER/AGENT
PRODUCER AGENCY
(If this is a Florida Risk, Producer means Florida Licensed Agent)
PRODUCER LICENSE NUMBER
(If this a Florida Risk, Producer means Florida Licensed Agent)
ADDRESS (STREET, CITY, STATE, ZIP)
PI-PRD-New App (12/09)
Page 4 of 5
© 2017 Philadelphia Consolidated Holding Corp.
10/2017
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ADDITIONAL INFORMATION
This section may be used to provide additional information to any question on this application. Please
identify the question number to which you are referring.
__________________________________________
Signature Date
PI-PRD-New App (12/09)
Page 5 of 5
© 2017 Philadelphia Consolidated Holding Corp.
10/2017
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Completed 7 November 2020

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