Burnette Insurance Agency, Inc. -- Simplified EPL Insurance Quote


Simplified EPL Insurance Quote		We would like to provide you with a free, no-obligation insurance quote. Please provide as much information possible for the most accurate quote. This information will be kept confidential and will be used for quote purposes only.

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

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 past 5 years, has any administrative hearing / claim been made or is now pending against the organization? Yes
No

Is any person aware of any fact or circumstance that may give rise to a claim under this policy? Yes
No

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 anticipated to be any reduction in staff in the past / future 12 months? If YES, explain:
Yes
No

Does the Insured have an "Employment At Will" statement? Yes
No

Does the handbook state that it is "not a contract"? Yes
No

Is EPL coverage in place currently? If YES:
a) Inception date of first policy: b) Current Carrier: Yes
No

Additional Comments

Please give any additional comments you feel appropriate for this quotation. If you have additional information where there was not enough fields above, please enter them here.

Please click on the "Submit Quote" button to send your quote request.
One of our representatives will respond to your submission as soon as possible.

Prior/Pending Claims
Within the past 5 years, has any administrative hearing / claim been made or is now pending against the organization?	Yes No
Is any person aware of any fact or circumstance that may give rise to a claim under this policy?	Yes No

Miscellaneous Information
Has there been, or is there anticipated to be any reduction in staff in the past / future 12 months? If YES, explain:	Yes No
Does the Insured have an "Employment At Will" statement?	Yes No
Does the handbook state that it is "not a contract"?	Yes No
Is EPL coverage in place currently? If YES: a) Inception date of first policy: b) Current Carrier:	Yes No