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Group Excess (PL) - EPL Coverage Request Form
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What is your first name?
What is your first name?
What is your last name?
What is your last name?
What is your email address?
What is your email address?
What is your employer's name?
What is your employer's name?
Who is responsible for managing the daily supervision, hiring, performance reviews and any disciplinary action of the domestic employee(s)?
Who is responsible for managing the daily supervision, hiring, performance reviews and any disciplinary action of the domestic employee(s)?
Primary Insured/Program Participant
Spouse of Primary Insured/Program Participant
Other Family Member
Non-Family Member
Business Manager
Other
What is the name of the person who manages the domestic employee(s)?
What is the name of the person who manages the domestic employee(s)?
Please describe this person's relationship to the primary insured/progam participant.
Please describe this person's relationship to the primary insured/progam participant.
Have you, your spouse, or a family member ever been accused of engaging in a wrongful employment act with residential/private staff of any household?
Have you, your spouse, or a family member ever been accused of engaging in a wrongful employment act with residential/private staff of any household?
Yes
No
Please explain the circumstances for each case.
Please explain the circumstances for each case.
Has any insurance company ever paid for damages or defense costs as a result of accusations brought against you, your spouse, or a family member related to a wrongful employment act?
Has any insurance company ever paid for damages or defense costs as a result of accusations brought against you, your spouse, or a family member related to a wrongful employment act?
Yes
No
Please explain the circumstances for each case.
Please explain the circumstances for each case.
Have you, your spouse, or a family member terminated any residential/private staff member from employment within the last three years?
Have you, your spouse, or a family member terminated any residential/private staff member from employment within the last three years?
Yes
No
Please explain the circumstances for each case.
Please explain the circumstances for each case.
Have you, your spouse or a family member ever had Employment Practices Liability declined, cancelled or non-renewed by any insurance company for any reason?
Have you, your spouse or a family member ever had Employment Practices Liability declined, cancelled or non-renewed by any insurance company for any reason?
Yes
No
Please explain the circumstances for each case.
Please explain the circumstances for each case.
How many residential staff do you employ?
How many residential staff do you employ?
Consent
*
Disclaimer: This online questionnaire is a tool used to gather information. It is not an application for insurance. No insurance coverage will be bound or put into effect by submitting this form.
Consumer disclosure: By checking the box below you authorize the Agency who supplied this form to you to contact you via phone, email, and text messaging; to save and share with business partners the information you provided; to obtain consumer reports that may include credit-based reports (where legally allowed), public records, claims history, and driving records so that they can give you accurate insurance quotes.
I agree
Michele Bolling
516-535-3550
http://www.hiramcohen.com
mbolling@hiramcohen.com
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