Application for “Claims Made” Insurance Policy

For Employment Practices and Discrimination Liability

1.	a.	Agency’s Legal Entity Name:

Federal Employer/Tax ID No.:

2. a. Street Address (Primary Location):

City:

County:	State:	Zip: -

b.	Mailing Address (if different from 2a):

City:	State:	Zip: -

3.	a.	Name of individual designated as agency E&O contact:

b.	Phone: ( )	c. Fax: ( )

d.	E-Mail Address:

Website Address:

4.	a.	Total number of U.S. employees (excluding owners*) who work over 20 hours per week:

b.	Total number of owners*:	*Owners are individuals with more than 10% ownership in the insured entity.

c.	Total number of part-time employees (20 hours per week or less):

d.	Number of employees with compensation greater than $100,000:

5.	a.	Who is responsible for Personnel/Human Resource functions and ADA compliance?

HR Department	Senior Management Outsourced None

b.	Years of Human Resource Experience: Less than 3 years 3 or more years

6. a. Do you have an employee handbook or manual that has been reviewed by an attorney? If Yes, complete 6. b.-i.	Yes	No
b. Is the handbook issued to all employees, with written acknowledgment of employee receipt?	Yes	No
c. Do changes to the handbook require the employee’s written acknowledgment of receipt?	Yes	No
d. Does the handbook address: Sexual harassment?	Yes	No
Discrimination?	Yes	No
Termination grounds and procedures?	Yes	No
e. Does the handbook contain a disclaimer stating that it is not an employment contract?	Yes	No
f. Does the handbook contain procedures for progressive discipline?	Yes	No
g. Does the handbook contain statements requiring termination be based on “just cause”?	Yes	No
h. Does the handbook contain procedures for probationary periods?	Yes	No
i. Does the handbook have a clause that states that all employee disputes will be mandatorily arbitrated?	Yes	No

7. a. Do you use a formal, standardized employment application form that has been reviewed by an attorney?	Yes	No
b. Does application contain an “employment at will” statement?	Yes	No
c. Do you require the applicant’s signature on the application?	Yes	No
d. Do employment applications include an authorization allowing you to check references, and if relevant to the position, conviction records?	Yes	No
e. Are terms of a job offer, including salary and benefits, confirmed in writing?	Yes	No
8. Do you maintain written records of all disciplinary actions?	Yes	No
9. Do you have a formal annual review process for all employees?	Yes	No
10. Do you require physical examinations of job applicants? If Yes, do you do so only after a conditional offer of employment is made?	Yes	No
Yes	No
11. a. Do you conduct drug and alcohol testing on applicants or employees? If yes, do you have policies/procedures addressing the scope and results of testing?	Yes Yes	No No
b. If existing employees test positive, are they given an opportunity for treatment before termination?	Yes	No
12. Are qualifications/skills/aptitude/personality tests required for job applicants? If yes, are arrangements made to accommodate persons with disabilities?	Yes Yes	No No
13. Are all employee files maintained in a secure place?	Yes	No
14. a. Are employee medical records maintained?	Yes	No
b. Are medical records kept separate from other personnel records and secured?	Yes	No
c. Are there written guidelines that specify how and under what circumstances employee medical files can be inspected?	Yes	No
15. Have written emergency and/or evacuation procedures been reviewed to ensure that the needs of persons with disabilities have been considered?	Yes	No
16. Do you use private employment agencies to recruit job applicants? If yes, are they contractually required to comply with the Americans with Disabilities Act?	Yes	No
Yes	No
17. Are you in compliance with the Americans with Disabilities Act?	Yes	No
18. Are I-9 forms submitted to verify eligibility of individuals who were hired after 1986?	Yes	No
19. How many staff members have been terminated in each of the last three years and the basis for termination of each?
Last Year: Basis for Termination: Staff Reduction For Cause 2 Yrs. Prior: Basis for Termination: Staff Reduction For Cause 3 Yrs. Prior: Basis for Termination: Staff Reduction For Cause
20. Indicate the annual turnover rate for last three years? Last Year: % 2 Yrs. Prior: % 3 Yrs. Prior: %
21. Are all federal/state mandated posters conspicuously displayed?	Yes	No
22. After inquiry of each agency personnel, are there any known circumstances or incidents which may result in an employment or ADA related claim being made against the agency?	Yes	No
If yes, what is the total number of these potential claims?
Complete a Claim Supplement for each potential claim. (Not required for claims or incidents previously reported to Westport Insurance Corporation’s Claims Dept.)
23. Have any employment or ADA related claims or incidents been made against the agency or any of its past or present personnel or predecessor agency, within the last 5 years?	Yes	No
If yes, what is the total number of these claims?
Complete a Claim Supplement for each claim/incident. (Not required for claims or incidents previously reported to Westport Insurance Corporation’s Claims Dept.)

24. Has any policy or application for employment practices insurance on behalf of the applicant or any of its past or present owners, officers, partners or employees or solicitors, or to the knowledge of the applicant, on behalf of its predecessors in business, ever been declined, canceled or renewal refused within the last 5 years?	Yes	No
If yes, please indicate: Year: Reason: Claim Experience Carrier withdrew from market Agency Operations Non-Payment Other (Describe)
25. a. Has the agency attended an WIC approved employment practices loss control seminar?	Yes	No
b. Has the agency implemented an employment practices risk management service during the past year?	Yes	No

26.	Please provide the following on the agency’s prior 5 years of employment practices insurance: ( if “None” )

Name of Carrier	Expiration Date	Limit of Liability	Deductible	Premium	Policy Retro Date if “Full Prior Acts”, box
/ /	$	$	$	/ /
/ /	$	$	$	/ /
/ /	$	$	$	/ /
/ /	$	$	$	/ /
/ /	$	$	$	/ /

27.	Requested Effective Date: / /

28.	Requested Limit: $100,000 $500,000 $1,000,000 $2,000,000 $3,000,000 $4,000,000 $5,000,000

29.	Requested Deductible: $5,000 $10,000 $15,000 $25,000 $50,000

NOTICE TO APPLICANT

For your protection, the following Fraud Warnings are required to appear on this application.

I hereby authorize the release of claim information from any prior insurer to us.

I understand and accept that the policy applied for provides coverage on a claims-made basis for only those claims that are made against the insured while the policy is in force and that coverage ceases with the termination of the policy. All claims will be excluded that result from any acts, circumstances or situations known prior to the inception of coverage being applied for, that could reasonably be expected to result in a claim.

The following Fraud Warning applies to Arkansas: 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.

The following Fraud Warning applies to Colorado: 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 policy holder 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.

The following Fraud Warning applies to Florida: 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.

The following Fraud Warning applies to Hawaii: For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or benefit is a crime punishable by fines or imprisonment, or both.

The following Fraud Warning applies in Kentucky: Any person who knowingly and with intent to defraud any insurance company or other person, files an application for insurance 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.

The following Fraud Warning applies to Louisiana: 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.

The following Fraud Warning applies in New Jersey: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties.

The following Fraud Warning applies in New Mexico: 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 civil fines and criminal penalties.

The following Fraud Warning applies in Ohio: 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.

The following Fraud Warning applies in Oklahoma: 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.

The following Fraud Warning applies in Oregon: 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 may be guilty of insurance fraud.

The following Fraud Warning applies in Pennsylvania: 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.

The following Fraud Warning applies in Maine/Tennessee/Virginia: 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.

The following Fraud Warning applies in All Other States: Any person who knowingly 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 also punishable by criminal and/or civil penalties in certain jurisdictions.

Applicant understands and agrees that the completion of the application does not bind Westport Insurance Corporation to issuance of an insurance policy.

THE APPLICATION MUST BE SIGNED AND DATED BY AN OWNER, OFFICER OR PARTNER.

Signature:	Date: / /

Name:	Title:

(Please Print)

The applicant understands and agrees that she or he is obligated to report any changes in the information provided in this application which occur after the date of the application.