United Agencies inc

Hing & Associates Insurance Brokers Inc.

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Employer Practices Liability Form :

General Information
Name of Insured:
Address:
City:
State:
Zip:
Business Phone:
Business Fax Number:
Email Address:
Year Organized:
Does Insured Have Any Subsidiaries?	Yes No If YES, STOP... please call to discuss this with one of our representatives

Employee Information
# of Full Time Employees:
# of Part Time Employees:
# of Employees within Salary Range:
$1-30,000
$30,001-50,000
$50,001-100,000
$100,001-greater

Prior/Pending Claims

Within the last 5 years, has any administrative hearing / claim been made or is one now pending against the organization?

Yes

Is any person aware of any fact or circumstance that might give rise to a claim under this policy?

Yes

Operations/Procedures
Nature of Operations:
Does the insured have written policies / procedures on:
Hiring/Firing	Yes No
Sexual Harassment	Yes No
Discrimination	Yes No
Is there a Human Resource Department?	Yes No

Miscellaneous Information

Has there been, or is there any anticipation of a reduction in staff over the past / future 12 months? If YES, explain:

Yes

Does the Insured have an "Employment At Will" statement?

Yes

Does the handbook state that it is "not a contract"?

Yes

Is EPL coverage currently in place ? If YES:

Yes

a) Inception date of first policy: b) Current Carrier:

Additional Comments

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