| Section Name | Field Name | Field and/or Section Description |
| This form is used to apply for employment practicesliability insurance coverage. The form | ||
| may be used as a stand-alone application, or it may be used in conjunction with ACORD | ||
| TITLE | Employment Practices Liability | 825 – Professional / Specialty Insurance Application, when other professional or specialty |
| ACORD 827 (2008/01) | Insurance Section | coverages are being applied for. |
| IDENTIFICATION SECTION | Date | Month/day/year (MM/DD/YYYY) on which the form is completed. |
| IDENTIFICATION SECTION | Agency | Agency’s name and address. |
| Named Insured as it appears on the ACORD 825 – Professional / Specialty Insurance | ||
| IDENTIFICATION SECTION | Named Insured | Application. |
| IDENTIFICATION SECTION | DBA | Indicate what insured is doing business as. |
| IDENTIFICATION SECTION | Policy Number | Use this field to provide the policy number if a policy has already been issued. |
| Name of the applicable insurance company. Do not use group names; use the actual | ||
| IDENTIFICATION SECTION | Carrier | name of the company within the group in which you wish to have the policy issued. |
| IDENTIFICATION SECTION | NAIC Code | Individual company code assigned by the NAIC. |
| NOTE: IF A POLICY IS ISSUED, IT WILL BE ON A CLAIMS-MADE BASIS. THE POLICY PROVIDES THAT THE LIMIT OF LIABILITY | ||
| AVAILABLE TO PAY JUDGMENTS ORSETTLEMENTS SHALL BE REDUCED BY | ||
| AMOUNTS INCURRED FOR LEGAL DEFENSE. | ||
| FURTHER NOTE THAT AMOUNTS INCURRED FOR LEGAL DEFENSE SHALL BE | ||
| IDENTIFICATION SECTION | APPLIED AGAINST THE RETENTION AMOUNT. | |
| COVERAGE REQUESTED | Limit Per Claim | Please indicate the limit per claim. |
| COVERAGE REQUESTED | Aggregate Limit | Please indicate the limit per aggregate. |
| COVERAGE REQUESTED | Retention Per Claim | Please indicate the retention per claim. |
| COVERAGE REQUESTED | Aggregate Retention | Please indicate the retention per aggregate. |
| COVERAGE REQUESTED | Annual Premium | Indicate the annual premium for this coverage. |
| The requested month/day/year on which the terms and conditions of the policy will | ||
| COVERAGE REQUESTED | Effective Date | commence. (MM/DD/YYYY) |
| Month/day/year on which the terms and conditions of the policy will terminate unless | ||
| COVERAGE REQUESTED | Expiration Date | renewed. (MM/DD/YYYY) |
| COVERAGE REQUESTED | Separate Defense Costs Limits | Indicate the separate defense costs limits for this coverage. |
| COVERAGE REQUESTED | Defense Limit – Inside | Indicate whether there is an inside defense limit. |
| COVERAGE REQUESTED | Defense Limit – Outside | Indicate whether there is an outside defense limit. |
| COVERAGE REQUESTED | Pending & Prior Litigation Date | Indicate the pending & prior litigation date. |
| COVERAGE REQUESTED | 1. Is the applicant requesting coverage for company and directors & officers? | |
| COVERAGE REQUESTED | 2. Is the applicant requesting coverage for employees? | If “yes”, indicate the total #. |
| COVERAGE REQUESTED | 3. Is the applicant requesting coverage for leased employees? | If “yes”, indicate the total of the following: # of full time employees, # of part time employees, # of temporary workers, # of seasonal workers. |
| COVERAGE REQUESTED | Number Of Full Time Employees | Indicate the total number of full time employees. |
| COVERAGE REQUESTED | Number Of Part Time Employees | Indicate the total number of psrt time employees. |
| COVERAGE REQUESTED | Number Of Temporary Employees | Indicate the total number of temporary employees. |
| COVERAGE REQUESTED | Number Of Seasonal Workers | Indicate the total number of seasonal workers. |
| COVERAGE REQUESTED | 4. Is the applicant requesting coverage for independent contractors? | |
| COVERAGE REQUESTED | Total Number Of Independent Contractors | If “yes”, indicate the total number. |
| COVERAGE REQUESTED | 5. Is the applicant requesting coverage for non-profit outside positions? | |
| COVERAGE REQUESTED | Total Number Of Volunteers | If “yes”, indicate the total # of volunteers. |
| COVERAGE REQUESTED | 6. Is the applicant requesting coverage for punitive damages? | |
| COVERAGE REQUESTED | Punitive Damages Limit | If “yes”, indicate the punitive damage limit. |
| COVERAGE REQUESTED | 7. Is the applicant requesting coverage for third party claim? | |
| SHARED LIMITS | Shared Limits | Indicate if there are shared limits. |
| SHARED LIMITS | Additional Coverages Attached | Indicate if additional coverages are attached. |
| SHARED LIMITS | Indicate Sections Included | Indicate the the additional coverages that are attached to complete the submission. If there are any other additional forms attached enter the form number next to the blank check box. Additional ACORD forms, such as state-specific forms, may also be filled in. |
| EMPLOYEE INFORMATION | In United States | Indicate total number of employees in the United States in parent company and all subsidiaries. |
| EMPLOYEE INFORMATION | Outside United States | Indicate total number of employees outside the United States in parent company and all subsidiaries. |
| EMPLOYEE INFORMATION | Unionized | Indicate total number of unionized employees in parent company and all subsidiaries. |
| EMPLOYEE INFORMATION | Fair Labor Standards ActExempt | Indicate total number of Fair Labor Standards Act Exempt employees in parent company and all subsidiaries. |
| EMPLOYEE INFORMATION | Fair Labor Standards Act Non Exempt | Indicate total number of Fair Labor Standards Act Non Exempt employees in parent company and all subsidiaries. |
| EMPLOYEE INFORMATION | Exempt – Less Than Or Equal To $50,000 | Indicate the percentage of exempt employees with salaries (including bonuses) less than or equal to $50,000. |
| EMPLOYEE INFORMATION | Exempt – Greater Than $50,000 But Less Than Or Equal To $100,000 | Indicate the percentage of exempt employees with salaries (including bonuses) greater than $50,000 but less than or equal to $100,000. |
| EMPLOYEE INFORMATION | Exempt – Greater Than $100,000 | Indicate the percentage of exempt employees with salaries (including bonuses) greater than $100,000. |
| EMPLOYEE INFORMATION | Non Exempt – Less Than Or Equal To $50,000 | Indicate the percentage of non exempt employees with salaries (including bonuses) less than or equal to $50,000. |
| EMPLOYEE INFORMATION | Non Exempt – Greater Than $50,000 But Less Than Or Equal To $100,000 | Indicate the percentage of non exempt employees with salaries (including bonuses) greater than $50,000 but less than or equal to $100,000. |
| EMPLOYEE INFORMATION | Non Exempt – Greater Than $100,000 | Indicate the percentage of non exempt employees with salaries (including bonuses) greater than $100,000. |
| EMPLOYEE INFORMATION | Union – Less Than Or Equal To $50,000 | Indicate the percentage of union employees with salaries (including bonuses) less than or equal to $50,000. |
| EMPLOYEE INFORMATION | Union – Greater Than $50,000 But Less Than Or Equal To $100,000 | Indicate the percentage of union employees with salaries (including bonuses) greater than $50,000 but less than or equal to $100,000. |
| EMPLOYEE INFORMATION | Union – Greater Than $100,000 | Indicate the percentage of union employees with salaries (including bonuses) greater than $100,000. |
| EMPLOYEE INFORMATION | 1. Does the applicant have any employees located outside the primary state of operations, including outside of the United States? | If “yes”, list the state or country and the number of employees. |
| EMPLOYEE INFORMATION | State | Please indicate the state. |
| EMPLOYEE INFORMATION | Country | Please indicate the country. |
| EMPLOYEE INFORMATION | Number Of Employees | Please indicate the number of employees. |
| EMPLOYEE INFORMATION | 2. Does the applicant have a tracking system that monitors the overtime, vacation and sick pay hours of non-exempt employees? | |
| EMPLOYEE INFORMATION | 3. Were any employees or officers terminated or do you plan in the next 18 months to terminate any employees or officers? | If “yes”, how many:_______, provide details. |
| REMARKS | REMARKS | Use this section to list any additional, pertinent information that the underwriter should know about the overall exposures of this risk. |
| FINANCIAL INFORMATION | Date of Financial Information | Indicate the date of the financial information. |
| FINANCIAL INFORMATION | Period of Financial Information From | Indicate the starting date of the financial information. |
| FINANCIAL INFORMATION | Period of Financial Information To | Indicate the ending date of the financial information. |
| FINANCIAL INFORMATION | Outside Auditor | Indicate if there is an outside auditor. If Yes, please answer the following: |
| FINANCIAL INFORMATION | 1. Any changes to the outside financial auditor in the last three (3) years? (Y/N) | |
| FINANCIAL INFORMATION | 2. Has any auditor issued a “Going Concern” opinion for the applicants or any of its subsidiaries financial statements? (Y/N) | |
| FINANCIAL INFORMATION | Current Year: Total Assets | Indicate the total assets for the current year. |
| FINANCIAL INFORMATION | Current Year:Current Assets | Indicate the current assets for the current year. |
| FINANCIAL INFORMATION | Current Year: Inventory | Indicate the inventory for the current year. |
| FINANCIAL INFORMATION | Current Year: Cash | Indicate the cash amount for the current year. |
| FINANCIAL INFORMATION | Current Year: Current Liabilities | Indicate the current liabilites for the current year. |
| FINANCIAL INFORMATION | Current Year: Total Liabilities | Indicate the total liabilites for the current year. |
| FINANCIAL INFORMATION | Current Year: Total Revenue | Indicate the total revenue for the current year. |
| FINANCIAL INFORMATION | Current Year: Net Income / Loss | Indicate the net income / loss for the current year. |
| FINANCIAL INFORMATION | Prior Year: Total Assets | Indicate the total assets for the prior year. |
| FINANCIAL INFORMATION | Prior Year: Current Assets | Indicate the current assets for the prior year. |
| FINANCIAL INFORMATION | Prior Year: Inventory | Indicate the inventory for the prior year. |
| FINANCIAL INFORMATION | Prior Year: Cash | Indicate the cash amount for the prior year. |
| FINANCIAL INFORMATION | Prior Year: Current Liabilities | Indicate the current liabilites for the prior year. |
| FINANCIAL INFORMATION | Prior Year: Total Liabilities | Indicate the total liabilites for the prior year. |
| FINANCIAL INFORMATION | Prior Year: Total Revenue | Indicate the total revenue for the prior year. |
| FINANCIAL INFORMATION | Prior Year: Net Income / Loss | Indicate the net income / loss for the prior year. |
| 1. Has the applicant had any actual or attempted merger, acquisition, consolidation or divestment in the | ||
| CORPORATE HISTORY | past six (6) years or anticipated in the next 18 months? | If “yes”, provide actual or anticipated date of action and details. |
| 2. Has the applicant in the past 36 months completed or agreed to, or does it anticipate within the next 18 months, any plant, facility, branch or office closings, consolidations or layoffs? | ||
| CORPORATE HISTORY | If “yes”, provide actual or anticipated date of action and details. | |
| 1. Does the applicant have a | ||
| human resources department? | ||
| EMPLOYMENT POLICIES / | ||
| PROCEDURES | ||
| Number Of Employees | If “yes”, indicate the number of employees. | |
| Human Resource Function | If “no”, indicate who handles this function. | |
| 2. Does the applicant require | ||
| employment terminations to be | ||
| reviewed by: | ||
| EMPLOYMENT POLICIES / | ||
| PROCEDURES | Check all that apply. | |
| EMPLOYMENT POLICIES / | Indicate if the applicant require employment terminations to be reviewed by human | |
| PROCEDURES | a. Human Resources | resources. |
| EMPLOYMENT POLICIES / | Indicate if the applicant require employment terminations to be reviewed by the legal | |
| PROCEDURES | b. legal department | department. |
| EMPLOYMENT POLICIES / | Indicate if the applicant require employment terminations to be reviewed by outside legal | |
| PROCEDURES | c. outside legal counsel | counsel. |
| EMPLOYMENT POLICIES / PROCEDURES | 3. What outside employment legal counsel does the applicant use for employment and/or labor advice and/or defense? | |
| 4. Does the applicant conduct | ||
| testing for: | ||
| EMPLOYMENT POLICIES / | Check all that apply. If any are checked, attach a copy of any written policies and | |
| PROCEDURES | procedures. | |
| EMPLOYMENT POLICIES / | ||
| PROCEDURES | Drug / Alcohol Screening | Indicate if the applicant conducts testing for Drug / Alcohol Screening. |
| EMPLOYMENT POLICIES / | ||
| PROCEDURES | Physical Examinations | Indicate if the applicant conducts testing for Physical Examinations. |
| EMPLOYMENT POLICIES / | ||
| PROCEDURES | Psychological Examinations | Indicate if the applicant conducts testing for Psychological Examinations. |
| EMPLOYMENT POLICIES / | ||
| PROCEDURES | Skills Testing | Indicate if the applicant conducts testing for Skills Testing. |
| EMPLOYMENT POLICIES / | ||
| PROCEDURES | Polygraph Testing | Indicate if the applicant conducts testing for Polygraph Testing. |
| EMPLOYMENT POLICIES / | ||
| PROCEDURES | Background Checks | Indicate if the applicant conducts testing for Background Checks. |
| EMPLOYMENT POLICIES / | ||
| PROCEDURES | Individual Conducting The Testing | Indicate the individual conducting the testing. |
| EMPLOYMENT POLICIES / | Testing/Examination(s) Is/Are | |
| PROCEDURES | Done: | Check all that apply. |
| EMPLOYMENT POLICIES / | ||
| PROCEDURES | Pre-Employment | Indicate if Testing/Examination(s) are done pre-employment. |
| EMPLOYMENT POLICIES / | ||
| PROCEDURES | Post Offer Of Employment | Indicate if Testing/Examination(s) are done post offer of employment. |
| EMPLOYMENT POLICIES / | 5. Are all employees subject to | |
| PROCEDURES | these tests and examinations? | If “no”, indicate which employees are not subject to these tests and examinations and why. |
| 6. Does the applicant use an | ||
| employment application for all | ||
| EMPLOYMENT POLICIES / | applicants? | If “no”, indicate which applicants are not required to complete an application and then |
| PROCEDURES | how is the hiring process conducted. | |
| 7. Does the applicant utilize | ||
| standard offer letters for all | ||
| EMPLOYMENT POLICIES / | applicants? | |
| PROCEDURES | If “no”, which applicants are not provided with employment offer letters and why. | |
| 8. Does the applicant have a | ||
| EMPLOYMENT POLICIES / | formal orientation program for all | |
| PROCEDURES | new employees? | |
| 9. Does the applicant provide | ||
| annual written performance | ||
| evaluations for all employees? | ||
| EMPLOYMENT POLICIES / | ||
| PROCEDURES | ||
| EMPLOYMENT POLICIES / | If “yes”, does it include standard | |
| PROCEDURES | rating categories? | |
| 10. Does the applicant conduct | ||
| training on sexual harassment and | If “yes”, indicate the following: | |
| discrimination prevention? | ||
| EMPLOYMENT POLICIES / | ||
| PROCEDURES | ||
| EMPLOYMENT POLICIES / | ||
| PROCEDURES | a. Who is required to attend? | |
| EMPLOYMENT POLICIES / | ||
| PROCEDURES | b. How often is it held? | |
| EMPLOYMENT POLICIES / | ||
| PROCEDURES | c. Who conducts the training? | |
| EMPLOYMENT POLICIES / | ||
| PROCEDURES | d. Is training documented? | |
| 11. Does the applicant have a | ||
| EMPLOYMENT POLICIES / | formal contract with any | |
| PROCEDURES | employee? | If “yes”, provide a specimen copy of the employment contract(s). |
| EMPLOYMENT POLICIES / PROCEDURES | If “yes”, is/are employment contract(s) created and reviewed by outside counsel? | |
| EMPLOYMENT POLICIES / PROCEDURES | Total Number Of Employees With A Formal Employment Contract | Indicate the total number of employees with a formal employment contract. |
| EMPLOYMENT POLICIES / PROCEDURES | Total Value Of All Contracts | Indicate the total value of all contracts. |
| EMPLOYMENT POLICIES / PROCEDURES | Total Value Of Largest Contract | Indicate the total value of largest contract. |
| EMPLOYMENT POLICIES / PROCEDURES | 12. Does the applicant have an employee handbook? | |
| EMPLOYMENT POLICIES / PROCEDURES | If “yes”, is it distributed to all employees? | |
| EMPLOYMENT POLICIES / PROCEDURES | 13. Do all employees provide a written acknowledgement that they have received the handbook? | |
| EMPLOYMENT POLICIES / PROCEDURES | 14. Is the employee handbook uniform for all locations and subsidiaries? | |
| EMPLOYMENT POLICIES / PROCEDURES | 15. Has an employment attorney reviewed the employee handbook? | |
| EMPLOYMENT POLICIES / PROCEDURES | 16. Are uniform exit interviews conducted when an employee resigns or is terminated (voluntary and involuntary)? | |
| EMPLOYMENT POLICIES / PROCEDURES | If “yes”, are exit interviews documented? | |
| 17. Is the applicant required to file | ||
| an affirmative action plan with the | ||
| office of federal contract | ||
| EMPLOYMENT POLICIES / | compliance programs (ofccp)? | |
| PROCEDURES | If “yes”, provide a copy of the plan. | |
| EMPLOYMENT POLICIES / PROCEDURES | 18. Has the applicant ever been the subject of an ofccp investigation which resulted in the finding of a violation? | If “yes”, attach a copy of the audit or investigation report and indicate what actions applicant has taken to remedy the violation. |
| 19. Does the applicant utilize | ||
| EMPLOYMENT POLICIES / | arbitration for employment- related | |
| PROCEDURES | claims? | |
| EMPLOYMENT POLICIES / | 20. Is arbitration for employment- | |
| PROCEDURES | related claims mandatory? | If “yes”, provide a copy of the arbitration policy. |
| 21. Are all applicant’s locations | ||
| compliant with the Americans with | ||
| EMPLOYMENT POLICIES / | Disabilities Act (ada)? | |
| PROCEDURES | If “no”, provide details. | |
| 1. Has any insured been involved in a civil or criminal action, administrative proceeding, investigation or charging violation by the equal employment opportunity commission (eeoc) or similar federal, state or foreign employment law or regulation? | ||
| GENERAL INFORMATION | ||
| 2. Has any insured been involved | ||
| GENERAL INFORMATION | in any other criminal actions? | |
| GENERAL INFORMATION | 3. Has any insured been involved in any representative actions, class actions or derivative suits in connection with employment issues? | |
| GENERAL INFORMATION | 4. Is any insured presently subject to any judicial or administrative order, decree, judgment or conciliation agreement that is employment- related? | |
| REMARKS | REMARKS | Use this section to list any additional, pertinent information that the underwriter should know about the overall exposures of this risk. |