Request employment practices quote

Type of business: *

Year business was organized: *

Do you have any subsidiaries: *

Please provide information about your employees

Number of full-time employees: *

Number of part-time employees: *

Number of employees within salary range of $1-$30,000: *

Number of employees within salary range of $30,001 to $50,000: *

Number of employees within salary range of $50,001 to $100,000: *

Number of employees with a salary higher than $100,001: *

Please provide information about your claims history

Within the past 5 years, has any administrative hearing/claim been made or is now pending: *

Is any person aware of any fact or circumstance that may give rise to a claim under this policy: *

Please provide information about your procedures

Do you have written policies/procedures on hiring and firing: *

Do you have written policies/procedures on sexual harassment: *

Do you have written policies/procedures on discrimination: *

Do you have a human resource department: *

Has there been or is there expected to be any reduction in staff in the past/future 12 months: *

Do you have an "Employment at Will" statement: *

Is employment practices liability coverage in place currently: *

Contact Name: *

E-mail address: *

Telephone number: *

What is the best time to contact: *

How did you hear about us?: *

Comments or additional information:

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