A85 (08/04)
Supplemental Application For Employee Benefits Liability
I. GENERAL INFORMATION
1. Proposed Insured:
2. Street Address:
3.City State Zip
Applicant’s Web Site Address:
4. Limits of Liability requested: $ each claim $ aggregate
5. Do you offer an Employee Benefits Program? Yes No
6. Number of employees: U.S. Canada Other
7. Number of employees covered by the Employee Benefits Plan:
8. Number of employees in charge of administering the Employee Benefits Plan:
9. What are the qualifications of employee benefits counselors and benefits administrators?
10. Are personnel unfamiliar with the program counseling employees about benefits? Yes No
11. Are stock subscriptions or profit sharing plans equally available to all full-time employees? Yes No
12. Is the Employee Benefits Program offered to non-employees?
Yes No
13. Employee Benefits Programs which are automatically covered without being specifically listed by the applicant are:
Group Life Insurance, Disability, Dental Benefits Insurance, Group Accident or Health Insurance, Unemployment
Insurance, Social Security Benefits, and Workers Compensation and Disability.
Indicate any other type of benefits that are desired:
a) b) c) d)
Describe:
14. Is all correspondence regarding applicant’s Employee Benefit Program made in writing? Yes No
15. Does your company form part of a franchise? Yes No
16. If multiple locations exist, is administration centralized?
Yes No
If no, explain
17. Number of branches, other business location:
18. How are employees in branches and other locations advised of benefits?
Describe:
19. Who was your prior carrier?
20. Has coverage ever been declined or cancelled? Yes No
If yes, please explain
21.
Are you aware of any claims that have been or will be brought against you
regarding the Employee Benefits Program?
Yes No
If yes, please explain
22. Has any error or omission loss ever been sustained?
Yes No
If yes, give details
23. Does the applicant have knowledge of an occurrence, which might result in a claim?
Yes No
If yes, describe
Member Companies of Western World Insurance Group
Western World Insurance Company
Tudor Insurance Company
Stratford Insurance Company
