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PRIVATE COMPANY PROTECTION PLUS
EMPLOYMENT PRACTICES LIABILITY INSURANCE
NON-BINDING PREMIUM INDICATION FORM
(Premium Indications Are 1RWAvailable for Applicants Domiciled in California)
Whenever used in this form, the term Applicant shall mean the Named Corporation and its wholly-owned /
controlled subsidiaries and their respective employees.
1.
Full Name of the Applicant:
2. Address:
3. Date established:
4. Website Address: www.
5.
Please describe the nature of the Applicant’s operations:
6.
Please provide the following employee information Currently One Year Ago
Total Full time (include leased, temporary and non-U.S. based employees):
Total Part time (include leased, temporary an non-U.S. based employees:
TOTAL NUMBER OF EMPLOYEES:
7. Number of employees located in the following states: CA: FL: NJ: NY: TX:
8. Current Coverage
Employment
Practices Coverage
Insurance Company
Limit of
Liability
Deductible
Effective
Date
Premium
Currently: $ $ $
9. Provide a list of all claims, suits or other demands for wages, reinstatement or other relief against the
Applicant in the past five years? Please check if none:
Representative or Authorized Agent (Please Print) Date
E-mail Address
Any offer of insurance coverage resulting from the submission of this Non-Binding Premium Indication
form shall be an estimate of premium costs, forms, terms and conditions. To secure a bindable quotation,
it will be necessary to complete a Private Company Protection Plus Employment Practices Liability
Insurance application and submit all required attachments.
For more information regarding our products or to download applications and forms, please visit our
website at www.phly.com.
© 2014 Philadelphia Consolidated Holding Corp
