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CARRIER:
EPL 5/14 – USLI
Employment Practices Liability Application – All States
THIS COVERAGE IS LIMITED TO CLAIMS FIRST MADE AND REPORTED TO THE COMPANY DURING THE POLICY PERIOD AS STATED IN THE DECLARATIONS OR ANY AP-
PLICABLE EXTENDED REPORTING PERIOD. DEFENSE COSTS SHALL BE APPLIED AGAINST THE RETENTION. PLEASE READ YOUR POLICY CAREFULLY.
New York Disclosure Notice: Under EPL 133 NY and EPL162 NY, if made part of your policy, or Section IV Exclusions C, the limits of liability available under this
policy may be completely exhausted by the payment of defense costs.
Applicant may qualify for an INSTANT QUOTE by completing Section I below. Section II and III answers will be required prior to binding and are subject to
underwriting approval.
I. INSTANT QUOTE INFORMATION
Instant quote is not available for accounts with losses in the past five years. If there is a loss history, please complete the application and
submit details in a USLI claim supplement.
Primary Applicant’s name
(See #4 to add subsidiary[ies]/affiliate[s]):
Location address:
City: State: Zip code:
Web address: Email address of primary contact:
Description of Operations:
Full-time employees: Part-time: Temporary/Seasonal Independent contractors Leased
How many of the above are located in: California: Florida Louisiana Outside the U.S.
II. UNDERWRITING INFORMATION
1. Year established:
2. Do more than 50% of all employees currently earn more than $100,000? q Yes q No
3. a. Is the applicant a subsidiary of another organization? q Yes q No
b. Is the applicant a franchisee of another organization? q Yes q No
c. Name of parent and/or franchisor and location:
4. Does the applicant want any subsidiary(ies)/affiliate(s) covered? q Yes q No
If “Yes,” include employees in employee count above and provide:
a. Name of subsidiary(ies)/affiliate(s):
b. Is the subsidiary(ies)/affiliate(s) at least 50% owned by the applicant? q Yes q No
c. Does the subsidiary(ies)/affiliate(s) fall within the same class of business as the applicant? q Yes q No
5. Expiring policy: Retroactive date: Carrier: Limits: Retention: Premium:
(Attach a statement of details for all “Yes” answers to the following questions)
6. a. Has any entity proposed for insurance closed, sold, merged with or acquired any company in the past
12 months or anticipates doing so in the next 12 months? q Yes q No
b. Has any entity proposed for insurance downsized, laid off or reduced staff in the past 12 months or
anticipates doing so in the next 12 months? q Yes q No
If “Yes,” what percentage of the workforce was/will be affected? %
7. Within the last five years, has any employment related, third party discrimination, or third party harassment inquiry,
complaint, notice of hearing, claim or suit been made against any entity proposed for insurance or any person
proposed for insurance in the capacity of either director, officer, member (if an LLC), or employee of any entity
proposed for insurance? If “Yes,” complete USLI Claim Supplement for each claim q Yes q No
8. Is any person proposed for this insurance aware of any fact, circumstance, or situation which may result in an
employment related, third party discrimination, or third party harassment claim against any entity proposed for
insurance or any of its directors, officers, members (if an LLC) or employees? q Yes q No
If “Yes,” complete USLI Claim Supplement for each claim.
9. Has any policy for employment practices liability insurance ever been cancelled or non-renewed by the carrier? q Yes q No
(Do not answer if applicant is located in Missouri)
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EPL 5/14 – USLI
IV. ADDITIONAL APPLICANT INFORMATION
Applicant’s mailing address:
City: State: Zip code:
FRAUD STATEMENTS
Alabama, Arkansas, District of Columbia, New Mexico, Rhode Island and West Virginia: Any person who knowingly presents a false or fraudulent claim
for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and
confinement in prison.
California: For your protection California law requires the following to appear on this application. Fraud Statement: Any person who knowingly presents false or
fraudulent information to obtain or amend insurance coverage or to make a claim for the payment of a loss is guilty of a crime and may be subject to fines and
confinement in state prison.
Colorado Fraud Statement: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose
of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company
or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of
defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the
Colorado division of insurance within the department of regulatory agencies.
Florida Fraud Statement: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application
containing any false, incomplete, or misleading information is guilty of a felony of the third degree.
Kansas Fraud Statement: Any person who, knowingly and with intent to defraud, presents, causes to be presented or prepares with knowledge or belief that
it will be presented to or by an insurer, purported insurer, broker or any agent thereof, any written, electronic, electronic impulse, facsimile, magnetic, oral,
or telephonic communication or statement as part of, or in support of, an application for the issuance of, or the rating of an insurance policy for personal or
commercial insurance, or a claim for payment or other benefit pursuant to an insurance policy for commercial or personal insurance which such person knows
to contain materially false information concerning any fact material thereto; or conceals, for the purpose of misleading, information concerning any fact material
thereto; or conceals , for the purpose of misleading, information concerning any fact material thereto may be guilty of a crime and may be subject to fines and
confinement in prison.
Maine Fraud Statement: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding
the company. Penalties may include imprisonment, fines or a denial of insurance benefits
Maryland Fraud Statement: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or
willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
New Jersey Fraud Statement: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and
civil penalties.
Ohio Fraud Statement: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim
containing a false or deceptive statement is guilty of insurance fraud.
Oklahoma Fraud Statement: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds
of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.
Oregon Fraud Statement: Notice to Oregon applicants: Any person who, with intent to defraud or knowing that he is facilitation a fraud against an insurer,
submits an application or files a claim containing a false or deceptive statement may be guilty of insurance fraud.
Kentucky and Pennsylvania Fraud Statement: Any person who knowingly and with intent to defraud any insurance company or other person files an
application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any
fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.
Tennessee, Virginia and Washington Fraud Statement: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company
for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.
Fraud Statement (All Other States): Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false
information in an application for insurance may be guilty of a crime and may be subject to fines and confinement in prison.
STATE NOTICES
Arizona Notice: Misrepresentations, omissions, concealment of facts and incorrect statements shall prevent recovery under the policy only if the
misrepresentations, omissions, concealment of facts or incorrect statements are; fraudulent or material either to the acceptance of the risk, or to the hazard
assumed by the insurer or the insurer in good faith would either not have issued the policy, or would not have issued a policy in as large an amount, or would not
have provided coverage with respect to the hazard resulting in the loss, if the true facts had been made known to the insurer as required either by the application
for the policy or otherwise.
III. WRITTEN EMPLOYMENT GUIDELINES
q Applicant currently has a written e-mail/internet policy in place
OR
q Applicant agrees to implement a written email/internet policy within 60 days of the effective date of coverage OR
q Applicant does not have a written email/internet policy in place and will not implement such policy.
The written employment policies below are required to obtain coverage with USLI. By checking the boxes below and signing this
application, the applicant agrees they either have or will implement and maintain the policies below within sixty (60) days of the
effective date of coverage
q Applicant currently has a written anti-discrimination policy in place
OR
q Applicant agrees to implement a written anti-discrimination policy within 60 days of the effective date of coverage OR
q Applicant does not have a written anti-discrimination policy in place and will not implement such policy.
q Applicant currently has a written anti-harassment policy in place
OR
q Applicant agrees to implement a written anti-harassment policy within 60 days of the effective date of coverage OR
q Applicant does not have a written anti-harassment policy in place and will not implement such policy.
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Florida Surplus Lines Notice: (Applies only if policy is non-admitted) You are agreeing to place coverage in the surplus lines market. Superior coverage may be
available in the admitted market and at a lesser cost. Persons insured by surplus lines carriers are not protected under the Florida Insurance Guaranty Act with
respect to any right of recovery for the obligation of an insolvent unlicensed insurer.
Florida and Illinois Punitive Damage Notice: I understand that there is no coverage for punitive damages assessed directly against an insured under Florida
and Illinois law. However, I also understand that punitive damages that are not assessed directly against an insured, also known as “vicariously assessed
punitive damages”, are insurable under Florida and Illinois law. Therefore, if any Policy is issued to the Applicant as a result of this Application and such Policy
provides coverage for punitive damages, I understand and acknowledge that the coverage for Claims brought in the State of Florida and Illinois is limited to
“vicariously assessed punitive damages” and that there is no coverage for directly assessed punitive damages.
Maine Notice: The insurer is not permitted to withdraw any binder once issued, but a prospective notice of cancellation may be sent and coverage denied for
fraud or material misrepresentation in obtaining coverage. A policy may not be unilaterally rescinded or voided.
New York Disclosure Notice: This policy is written on a claims made basis and shall provide no coverage for claims arising out of incidents, occurrences or
alleged Wrongful Acts or Wrongful Employment Acts that took place prior to retroactive date, if any, stated on the declarations. This policy shall cover only those
claims made against an insured while the policy remains in effect for incidents reported during the Policy Period or any subsequent renewal of this Policy or any
extended reporting period and all coverage under the policy ceases upon termination of the policy except for the automatic extended reporting period coverage
unless the insured purchases additional extend reporting period coverage. The policy includes an automatic 60 day extended claims reporting period following
the termination of this policy. The Insured may purchase for an additional premium an additional extended reporting period of 12 months, 24 months or 36
months following the termination of this policy. Potential coverage gaps may arise upon the expiration for this extended reporting period. During the first several
years of a claims made relationship, claims-made rates are comparatively lower than occurrence rates. The insured can expect substantial annual premium
increases independent overall rate increases until the claims-made relationship has matured.
Ohio Representation Statement: By acceptance of this policy, the Insured agrees the statements in the application (new or renewal) submitted to the company
are true and correct. It is understood and agreed that, to the extent permitted by law, the Company reserves the right to rescind this policy, or any coverage
provided herein, for material misrepresentations made by the Insured. It is understood and agreed that the statements made in the insurance applications
are incorporated into, and shall form part of, this policy. THE INSURED UNDERSTANDS AND AGREES THAT ANY MATERIAL MISREPRESENTATION
OR OMISSION ON THIS APPLICATION WILL ACT TO RENDER ANY CONTRACT OF INSURANCE NULL AND WITHOUT EFFECT OR PROVIDE THE
COMPANY THE RIGHT TO RESCIND IT.
Utah Punitive Damages Notice: I understand that Punitive Damages are not insurable in the state of Utah. There will be no coverage afforded for Punitive
Damages for any Claim brought in the State of Utah. Any coverage for Punitive Damages will only apply if a Claim is filed in a state which allows punitive or
exemplary damages to be insurable. This may apply if a Claim is brought in another state by a subsidiary or additional location(s) of the Named Insured, outside
the state of Utah, for which coverage is sought under the same policy
Missouri and Rhode Island Disclosure Notice: I understand and acknowledge that if a $100,000 or $250,000 Limit of Liability is chosen or if the Insured
Organization has more than 200 employees, that Defense Costs are a part of the Limit of Liability. This means that Defense Costs will reduce my limits of
insurance and may exhaust them completely and should that occur, I shall be liable for any further legal Defense Costs and Damages. Defense Costs are as
defined in Section III. I also understand that the Limit of Liability for the Extended Reporting Period, if applicable, shall be a part of and not in addition to the limit
specified in the Policy Declarations.
Virginia Notice: This Policy is written on a claims-made basis. Please read the policy carefully to understand your coverage. You have an option to purchase
a separate limit of liability for the extended reporting period. If you do not elect this option, the limit of liability for the extended reporting period shall be part of
the and not in addition to limit specified in the declarations. If you have any questions regarding the cost of an extended reporting period, please contact your
insurance company or your insurance agent. Statements in the application shall be deemed the insured’s representations. A statement made in the application or
in any affidavit made before or after a loss under the policy will not be deemed material or invalidate coverage unless it is clearly proven that such statement was
material to the risk when assumed and was untrue.
If your state requires that we have information regarding your Authorized Retail Agent or Broker, please provide below.
Retail agency name: License #:
Agent’s signature: Main agency phone number:
(Required in New Hampshire)
Agency mailing address:
City: State: Zip:
The signer of this application acknowledges and understands that the information provided in this Application is material to the Insurer’s decision to provide the
requested insurance and is relied on by the Insurer in providing such insurance. The signer of this application represents that the information provided in this
Application is true and correct in all matters. The signer of this Application further represents that any changes in matters inquired about in this Application occurring
prior to the effective date of coverage, which render the information provided herein untrue, incorrect or inaccurate in any way will be reported to the Insurer
immediately in writing. The Insurer reserves the right to modify or withdraw any quote or binder issued if such changes are material to the insurability or premium
charged, based on the Insurer’s underwriting guides. The Insurer is hereby authorized, but not required, to make any investigation and inquiry in connection with
the information, statements and disclosures provided in this Application. The decision of the Insurer not to make or to limit any investigation or inquiry shall not be
deemed a waiver of any rights by the Insurer and shall not estop the Insurer from relying on any statement in this Application in the event the Policy is issued. It is
agreed that this Application shall be the basis of the contract should a Policy be issued and it will be attached and become a part of the Policy.
New York Fraud Statement: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance
or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto,
commits a fraudulent insurance act, which is a crime and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the
claim for each such violation.
Applicant’s signature: Title:
President, Chairperson of the Board, Managing Member, or Executive Director
Date:
EPL 5/14 – USLI
page 1 of 1Privacy Notice 11/21 – USLI
Privacy Notice At Collection
We may need to collect certain personal information to provide you with our services and products. For information
on how we store, use and protect personal information, please see our Privacy Policy accessible on our website,
https://www.usli.com/privacy-policy/.