For a free Employment Practices quote, complete the below.  
                                                           
This application is used to provide
quotes for employment practices.  
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Name
e-mail address:
Your phone number:
Company Name:
Address:
Company Established
(year)
Provide a brief description of  what your company does
by percentage(%).  For example, we provide IT
Consulting (50%), MSP (30%) and VAR Services (20%)
Confirm Total Revenues

Most Recent Financial Year:

Project for Next Financial Year:
Employee Info:

Total number of Staff  include full and part time for all locations
and subsidiaries.  Please count each part time employee as
1/2 employment:



Has the Company laid-off (excluding seasonal layoffs) or
terminated more than thirty percent (30%) of its workforce in
the past twelve (12) months?  

Does the Company anticipate any layoffs (excluding seasonal
layoffs), downsizing, or office or plant closings in the next
twelve (12) months?

If yes to the above two question, please request our Reduction
in Force Supplement .

Within the past three (3) years, has the Company had any
lawsuits, threatened claim, or charges filed with the EEOC or
state/local administrative agency involving a Wrongful
Employment Act, or Third-Party Wrongful Act?

Does any director, officer, owner, member, or partner of the
Company have knowledge of any fact, circumstance, or
situation which may result in a Claim, such as would fall under
the proposed insurance?

If yes to above two questions, please request our Claim
Supplement for each claim.

Does the Company currently have AND regularly distribute the
following written policies?

A.  Employment at-will statement

B.  Anti-Discrimination

C.  Harassment  

IMPORTANT LOSS PREVENTION NOTE: If the response to
either A, B, or C above is “No,” as a condition precedent to any
coverage bound, the Company agrees that it will adopt and
provide to all employees, such new written policies within 30
days of the inception of coverage. Sample policies will be
provided by the Insurer.  This is another risk management
service provided by TechRisks.com and underwriting partners.

Person responsible for receiving loss prevention material,
include their full name, title and email.
Yes                               no
name:
title:
email address:
How Did You Hear About Us?
Additional Comments /
Thoughts or Needs?
If you can insert an auto signature, do so here,
 If not, print your name.  Some underwriters
may require signed application upon binding.  
Declaration:
I hereby declare that I am authorized to complete this application on behalf of the applicant and that after
due inquiry, to the best of my knowledge and belief, the statements and particulars are true and complete
and no material faces have been misstated, suppressed or omitted.  I undertake to inform underwriters or
addition to these statements or particulars which occur before or during any contract of insurance based
on the applications is effected.  I also acknowledge that this application (together with any information
supplied to underwriters) shall be the basis of contract.   Certain Underwiters may require additionanl
information including their formal application to be signed subject to binding coverage.  

I understand that underwriters will rely on the statements that I make on this form.  In this context, any
insurance coverage that may be issued based upon this form will be void If the form contains falsehoods,
misrepresentations or omissions.   Click here to submit and agree to this declaration.
ATTACHED IS AN EMPLOYMENT PRACTICE RELATED DOCUMENTS THAT
MAY PROVIDE YOU ADDITIONAL INSIGHT.  
EPLI PROGRAM BROCHURE