TechRUG logo

Employment Practices Liability (EPL) Application

Company Name
Street Address, Include Floor #
City
State
Zip
Tel #
Contact Name
Contact Title
Contact Tel#
Contact e-mail
Website (if any)
Type of Business
Number of Locations
# Full Time Employees
# Part Time Employrees
Do you publish and distribute an employee handbook?
Have you had any losses or claims of wrongful terminations, discrimination or sexual harrassment (including lawsuite, EEOC/state charges and written demands) in the last 5 years?Do you currently have EPL insurance?
   
Carrier Name
Limits
Deductible
Premium
Effective Date
Continuity/Retroactive Date
Limit Requested ($1,000,000, $2,000,000, $3,000,000, other)
Deductible Requested ($5,000, $10,000, $25,000, other)

TechRUG - We've got IT covered!