Quick Form Employment Practices Liability Indication Worksheet
Prospective Insured/DBA:
Physical address (include city and zip code):
Nature of Business:
Website:
No. of Locations: Domestic:
Foreign:
Year Established:
Annual revenues:
Employee Count Information
Total
Full Time
Part Time
Independent
Contractors
Seasonal
Temporary
Union
H/R Controls
Yes
No
HR Manager on staff or uses Independent HR Management?
Use of an at will employment application?
Provides written job descriptions?
Provide all employees with a written performance evaluation?
Publish an employee handbook for all employees?
Handbook contains the following:
a. at will employment statement?
b. Signed employee acknowledgment?
c. Employee grievance policy and procedure?
d. Anti-harassment policy and procedure?
6. Anti-discrimination policy and procedure?
7. Requires all terminations reviewed by legal counsel?
8. In compliance with state regulatory harassment training?
9. Average turnover rate for the past 3 years:
%
10. Any executive or member of senior management voluntary or non-voluntary termination in the last 12 months?
Yes
No
If yes, please provide title of individual, date, and reason(s) for termination:
11. Any mergers, acquisitions, or layoffs anticipated in next 12 months?
Yes
No
If yes, please provide details:
1.
2.
3.
4.
5.
Current Employment Practices Liability Insurance (if applicable)
Expiration
date
Insurance Co.
Limit of
Liability
Deductible/Retention
Annual
Premium
Retro date
12. Has the prospective insured been involved in any claims or lawsuits or any investigations by the EEOC, DFEH
or any other regulatory agency in the past five years involving employment related claims, such as wrongful
termination discrimination or harassment?
Yes
No
If “Yes”- please provide details including nature of the allegations, the current status of the claim, and any legal
expenses incurred or paid and any settlement paid by the prospective insured or the insurance company: