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Employment Practices Liability

Person To Contact

Company Name *
Company Owner *
Street *
City *
State / Province *
ZIP / Postal Code *
Primary Phone Number *
E-Mail Address *
First Name *
Last Name *
Total # of Employees *
# of Full Time Employees *
# of Part-Time Employees *
Any Change In # of Employees Last 12 Months *
Any Anticipated Change in # of Employees Next 12 Months *
How Many Locations do you have *
Have You Been In Business Longer than 3 Years *

Do Over 50% of Employees Earn over $ 75,000 *

Any Locations in Louisana or outside us ? *

Do You Currently Have Employment Practices Liability Policy *

Current Insurance Provider
Current Policy End Date
/ /
Within the last 5 years has any employment related, or third party discrimination, or third party harassment inquiry, complaint , notice of hearing, claim or suit been made against the applicant *

Does Applicant have any email or internet policy currently in force ? *

Does Applicant have an Anti-Discrimination policy currently in force ? *

Any person aware of any fact, circumstances or situation which may result in any employment claim *

Submission Validation

Important Notice
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