Home
About Us
Products & Services
Blog
Get a Quote
About Us
Products & Services
Blog
Contact Us
978-400-7014
Please enable JavaScript in your browser to complete this form.
Employer Practices Liability Insurance
Company name:
Company address:
Company website:
State of incorporation:
Years of operation:
or recent the
Nature of your company’s business:
Most recent fiscal year gross revenue:
Has your company in the last 12 months completed any (check all that apply):
Reorganization or arrangement with creditors under federal or state law?
Branch, location, facility, office, or subsidiary closings, consolidations or reductions in workforce?
Is your company currently anticipating any of the above?
Financials
Please provide the most recent fiscal year and YTD balance sheet and income statement:
Click or drag files to this area to upload.
You can upload up to 10 files.
# of employees
Total
How many in CA?
How many in IL?
How many outside the US?
During the past 3 years has your company, in any capacity, been involved in any of the following:
EEOC or other similar administrative proceedings?
Yes
No
Any employment-related civil suit, claim, or other matter?
Yes
No
U.S. Employee Salary Ranges
Annual Employee Compensation Ranges (including bonuses) Approximate % in Range Current Year
Up to $50,000
Enter the percentage as a number (i.e. 10 to represent 10%)
$50,001 to $150,000
Enter the percentage as a number (i.e. 30 to represent 30%)
Greater than $150,000
Enter the percentage as a number (i.e. 60 to represent 60%)
Does your company have written policies regarding:
Equal Opportunity Employment?
Yes
No
Anti-discrimination?
Yes
No
Anti-harassment, including sexual harassment?
Yes
No
Do you, or others on your behalf or at your direction, collect, store, or transmit biometric information or biometric identifiers?
Yes
No
Employee Handbook
Please provide your company's current employee handbook, or equivalent, as an attachment:
Click or drag files to this area to upload.
You can upload up to 10 files.
If none exist or is not available, please confirm whether written procedures are in place regarding (check all that apply):
Progressive Discipline
Terminations
Handling complaints of harassment and discrimination
Leave of Absence including FMLA
Does your company (check all that apply):
Utilize outside counsel to review written policies and procedures?
Review terminations with outside counsel?
Conduct training regarding anti-discrimination and anti-harassment?
Review pay practices for inequities among protected class employees?
Require employees to attend diversity training?
Submit