Simplified EPL Insurance Quote   We would like to provide you with a free, no-obligation insurance quote. Please provide as much information possible for the most accurate quote. This information will be kept confidential and will be used for quote purposes only.   General Information Name of Insured:  Address:  City:    State:   Zip:  Business Phone:    Fax Number:  Email Address:  Year Organized:  Does Insured Have Any Subsidiaries? Yes No     If YES, STOP... please call to discuss   Employee Information # of Full Time Employees: # of Part Time Employees: # of Employees within Salary Range: $1-30,000    $30,001-50,000  $50,001-100,000    $100,001-greater      Prior/Pending Claims Within the past 5 years, has any administrative hearing / claim been made or is now pending against the organization? Yes No Is any person aware of any fact or circumstance that may give rise to a claim under this policy? Yes No   Operations/Procedures Nature of Operations: Does the insured have written policies/ procedures on: Hiring/Firing  Yes No Sexual Harassment  Yes No Discrimination  Yes No   Is there a Human Resource Department? Yes No   Miscellaneous Information Has there been, or is there anticipated to be any reduction in staff in the past / future 12 months?   If YES, explain: Yes No Does the Insured have an "Employment At Will" statement?  Yes No Does the handbook state that it is "not a contract"? Yes No Is EPL coverage in place currently?   If YES: a) Inception date of first policy:   b) Current Carrier:  Yes No   Additional Comments  Please give any additional comments you feel appropriate for this quotation. If you have additional information where there was not enough fields above, please enter them here. Please click on the "Submit Quote" button to send your quote request. One of our representatives will respond to your submission as soon as possible.