Employment Practice Liability Quick Quoting Form

Complete Name

Insured's Company Name

Email

Contact Number

Insured's State
—Please choose an option—AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

Physical Address

Website

NATURE OF BUSINESS

How long has the company been in operation?

Annual turnover estimate

Number of Full-Time Employees

Is the company stock publicly traded?
YesNo
Number of Temporary/Seasonal Employees

Number of Part-Time Employees

Number of Independent Contractors

Number of Leased Employees

Average Salary

Are any of the above located in the following areas?
CaliforniaLouisianaFloridaOutside the U.S.
Are there any additional entities or subsidiaries requesting coverage?
YesNo
In the past 5 years, has the applicant had a claim or is the applicant aware of any circumstances or incidents that may result in as claim?
YesNo
Are you interested in an optional Cyber Quote?
YesNo
Does the insured currently carry EPL coverage?
YesNo
If you have any supporting information, feel free to attach here

How did you hear about us?*
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