What is your first name? *
What is your last name? *
What is your email address? *
What is your phone number? *
What is your role and title at the business? *
Please select the coverages for which you are requesting a proposal. (Select all that apply)
General Information
What is the full legal name of the business? (The phrase "the business" used throughout this form refers to the applicant.) *
Does the business have another name? (ie. DBA)
What other name does the business operate under?
What is the mailing address for the business? *
Is the principle physical location address the same as the mailing address? *
What is the principle physical location address for the business? *
What date would you like this coverage to commence? *
MM slash DD slash YYYY
In which state is the business incorporated?
What date was the business established?
For Employment Practices Loss Prevention eligibility, please enter the individual responsible for Human Resources or employment law matters.
What is the website address for the business?
What legal entity type does the business have? *
Please enter the business's legal entity type. *
What is the business's Federal Employer Identification Number (FEIN)? *
How many years has the business been operating? *
Please select the category that fits this business. *
Please provide a description of the business's operations. *
Does the business currently have recognized tax-exempt status under the U.S. Internal Revenue Code?
Does the business have any subsidiaries or control any other entity or organization for which coverage is requested?
Please provide a description of the operations, ownership, and the tax status of each such entity.
Does the business or any subsidiary render any professional services, including but not limited to conducting any standard setting, accrediting, credentialing or licensing actives, for others for a fee?
Please provide a description of the professional services provided.
What was the business's total revenue for the most recent year end?
What were the business's total assets for the most recent year end?
In the next 12 months (or during the past 18 months) is the business contemplating (or has the business completed or been in the process of completing) any reorganization or arrangement with creditors under federal or state law?
Please provide an explanation.
In the next 12 months (or during the past 18 months) is the business contemplating (or has the business completed or been in the process of completing) any branch, location , facility, or office closings, consolidations or layoffs?
Please provide an explanation.
Has the business or any person proposed for coverage been the subject of, or involved in any anti-trust, copyright or patent litigation in the past five years?
Please provide an explanation.
Has the business or any person proposed for coverage been the subject of, or involved in any criminal actions in the past five years?
Please provide an explanation.
Has the business or any person proposed for coverage been the subject of, or involved in any litigation or other proceeding involving any allegation of discrimination in the past five years?
Please provide an explanation.
Has any claim been brought at any time during the last five years against: (i) any applicant or (ii) any proposed insured individual in his, her or their capacity as a director, officer or trustee of any entity?
Please provide an explanation.
Has the business given notice of any claim, circumstance or potential claim to any insurer under any of the coverages to which this form relates?
Please provide a full explanation of the claim, circumstance or potential claim and amount of payment made by insurer, if any.
Has the business been declined, canceled or non-renewed for any of the coverages to which this form relates?
Please provide an explanation.
Employment Practices Information
How many full time employees did the business have in the current and previous years?
How many part time employees did the business have in the current and previous years? (Include leased and seasonal)
How many employees were located in California during the current and previous years?
How many volunteers did the business have in the current and previous years?
Does the business have written procedures in place regarding equal opportunity employment?
Please provide a full explanation.
Does the business have written procedures in place regarding anti-discrimination?
Please provide a full explanation.
Does the business have written procedures in place regarding anti-sexual harassment?
Please provide a full explanation.
During the past three years, has the business or any applicant in any capacity, been involved in an EEOC, NLRB or other similar administrative proceeding?
Please provide a full explanation.
During the past three years, has the business or any applicant in any capacity, been involved in an employment-related civil suit?
Please provide a full explanation.
What was the annual employee turnover percentage rate for last year? (Past Year)
What was the annual employee turnover percentage rate for the year before last? (1 Year Previous)
What was the annual employee turnover percentage rate three years ago? (2 Years Previous)
How many involuntary terminations have occurred in the last year? (Past Year)
How many involuntary terminations have occurred in the year before last? (1 Year Previous)
Optional Third-Party Information
Applicant: Please complete this section only if requesting Employment Practices Liability coverage.
Does the business have established written polices or procedures outlining employee conduct when dealing with third parties, including non-discrimination and non-harassment statements?
Does the business have established written polices or procedures for responding to complaints of harassment, discrimination or civil rights violations from third parties?
What percentage of the business's employees and volunteers have direct contact with the general public?
Has the business ever had any action or civil suit brought against it by a customer, client or third party alleging harassment, discrimination, or civil rights violations?
Please provide a full explanation and details.
Fiduciary Information
Please complete the following information regarding the business's employee benefits plan(s). (Click the circle to the right of the table to add additional plans.)
- *Types of Plans:
Defined Contribution Plan =DCP
Defined Benefit Plan = DBP
Employee Stock Ownership Plan = ESOP
Excess Benefit Plan or Top Hat Plan = EBP
Does the business handle any investment decisions in-house?
Please provide an explanation.
Does each of the business's employee benefit plans conform to the standards of eligibility, participation, vesting and other provisions or ERISA?
Please provide an explanation.
Has any fiduciary been accused of, found guilty of, or held liable for a breach or trust?
Please provide an explanation.
Has any fiduciary been convicted of criminal conduct?
Please provide an explanation.
Has there been any assessment of fees, fines or penalties against any of the business's employee benefit plans under any voluntary compliance resolution program or similar voluntary settlement program administered by the IRS, DOL or other government authority?
Please provide an explanation.
Crime Information
Does the business maintain a list of authorized vendors?
Does the business verify invoices against a corresponding purchase order, receiving report and the authorized master vendor list prior to issuing payment?
Does the business allow the employees who reconcile the monthly bank statements to also sign checks or handle deposits?
Does the applicant perform pre-employment reference checks for all its potential employees?
Please provide an explanation.
Please describe the services the business provides for clients.
Has the business had any occurrences of employee theft, burglary, robbery, forgery, computer fraud or other crime in the last five years?
Please list all employee theft, burglary, robbery, forgery, computer fraud or other crime losses discovered by the business in the past five years. Itemize each loss separately; including date of loss, description and total amount.
Kidnap, Ransom and Extortion Information
Please complete the following information regarding the foreign travel of the business's employees. (Click the "plus" circle to the right of the table to add additional countries.)
Prior Insurance
Does the business have any insurance in place currently? *
Please select the coverages currently purchased by the business. *
Please enter the following information about the business's current Directors & Officers and Entity Liability policy.
Please enter the following information about the business's current Employment Practices Liability policy.
Please enter the following information about the business's current Fiduciary Liability policy.
Please enter the following information about the business's other policy.
Please upload copies of all applications submitted to the current insurer or any prior insurers.
Is the current carrier offering to renew the policy? *
What is the reason the current carrier is not offering to renew your policy?
Please upload a copy of the most recent CPA prepared financial statements.
Do you have a recent CPA Letter to Management and a response from management you can upload at this time?
Please upload a copy of the most recent CPA Letter to Management and management's response.
Documents and Comments
Please use this field to upload any relevant insurance documents.
Please enter any additional remarks in the space below.
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Please share who referred you to us.
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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.
