Use this form to apply for Employment Related Practices Liability coverage.
This form is intended to be used with ACORD 125, Commercial Insurance Application.
Provide the limit of insurance, co-payment amount, if any, and any other pertinent information required by the company.
Answer all questions. Note that current and prior coverage information relates only to the coverage request under this application.
Provide employee and subsidiary information as applicable.
EMPLOYMENT POLICY AND PRACTICES
Answer all questions to provide the underwriter with as much information as possible about the risk.
Provide details about any office closings, consolidations, layoffs, staff reductions, mergers or acquisitions within the past 24 months, or any such planned actions within the next 24 months.
RECENT EMPLOYMENT-RELATED ISSUES
Provide information about any employment related lawsuits or administrative proceedings that commenced in the past 3 years, and any currently existing legal orders or decrees. Also describe any circumstances that may have the potential to give rise to a claim.
NOTE: THE APPLICANT MUST INITIAL ANSWERS TO THESE QUESTIONS.
Refer to the company manual to determine which attachments are required by the policy rules.