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Employment Practice Liability Quotation Form

PHONE: (503)684-6598 or (800)468-5647
FAX: (503) 244-6881

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Account Information

Account Name:

Description of Operations:

Address:

City:

State:

Zip Code:

Country:

Phone:

Fax:

Email:

Agent Information

Agent Name:

Agent Email:

Agent Phone:

Agent Fax:

Employee Information

Number of Employees

Enter the number of employees located in each state. Part-time or seasonal employees count as 0.5 (one-half).

AZ	CA	CO
ID	MT	NV
OR	UT	WA

Employer Initiated
Termination Ratio

Involuntary departures (3 year avg): <= 5% > 5% and <= 10% > 10% and <= 20% Other

Turnover Ratio

Voluntary departures (3 year avg): <= 10% > 10% and <= 20% > 20% and <= 25% > 25% and <= 35% > 35%

Salaries over $100,000

<= 10% > 10% and <= 20% > 20% and <= 25% > 25%

Employment Policies & Procedures

Check all that apply: Published employee handbook. Published anti-discrimination policy. Published anti-harassment policy (not limited to 'sexual harassment'). Prominent at-will disclaimer (e.g. front of employee handbook). Signed acknowledgment employee has received and read handbook. Published leave policy.

Loss History

Number of Charges
and/or Complaints:

Paid Loss
including defense costs:

For Layoffs/Closings, consider the prior 24 and next 12 months.

If losses need loss runs and/or a description and payment amount,
enter that information here:

Coverage

Limits and Retentions

Desired Limit

$250 Thousand $500 Thousand $1 Million Other

Desired Retention

$5 Thousand $10 Thousand $15 Thousand Other

Request

Indication Other

Requested limits, retentions, or options may or may not be offered.

Third Party Coverage

Yes No

Retroactive Coverage

At Inception Consistent with Expiring Coverage Full Other (specify below)

Third Party and Retroactive coverage, if offered, are each subject to additional premium.

EPLI Coverage

Does the company currently carry EPLI coverage? Yes No

If yes, please provide the original inception date of the first policy written. Optionally, please provide other details including carrier, limit, retention and any special coverages:

Comments

Math Question:

What does nine plus six equal?
(Enter the numeral, not the text.)

The random math question helps stop SPAMbots from sending us junk email.

Please note:
This is for indication purposes only. No coverage is bound by clicking "submit". A representative of Nielsen Insurance Agency will contact you within 2 business days with an indication. A completed, signed application will be needed before coverage can be bound. The original signed application (not a copy) and the premium is required within 20 days of binding order.

If after receiving an indication you wish to proceed additional information will be required in order to secure coverage.

By clicking "Submit" I understand no coverage is bound and I am not authorized to bind coverage.