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EMPLOYMENT PRACTICES LIABILITY

*Contact Person:

Firm Name:

Address:

 
City:

* State:  Zip:

*Tel.:

   

Fax:

*E-mail:


(check applicable):

 Corporation
 Partnership
 Other

(check applicable):

 Sole Proprietorship
 Joint Venture

Length of time in business: 


Please list any predecessor firms here and provide information on ownership:
Staff Information
Number of lawyers: 

Number of support staff/ clerical/ student interns/ volunteers: 


List all lawyers below. Include Name/ Length of time with applicant/ Years Experience:

1. 
2. 
3. 
4. 
5. 
6. 
7. 
8. 
9. 
10. 
Human Resources

1. What is the firm's maximum annual percentage turnover rate for the past five years? 


2. How many employees or officers have been terminated with or without cause in the past two years?
employees:  officers? 


3. Does the applicant have employment agreements with any officers/ employees?   Yes    No


4. Does the applicant utilize an employment handbook that is distributed to all employees?   Yes    No


5. Does the applicant take steps to establish at-will employment relationship with employees?   Yes    No


6. Has the applicant adopted anti-discrimination policies or written procedures regarding the selection of employees for hiring, promotion, transfer, layoff, salary increase, work assignments and other employment-related areas?   Yes    No


7. Has the applicant implemented or adopted anti-sexual harassment policies or written procedures?   Yes    No


If yes, is it distributed annually to all workers?   Yes    No


8. Does the company have written procedures for handling employee complaints of discrimination and sexual harassment?
   Yes    No


9. Does the applicant require job applicants to use an employment application?   Yes    No


10. Does the applicant utilize progressive disciplinary procedures?   Yes    No


11. Does the company provide annual, written performance evaluations for all employees?   Yes    No


12. Does the applicant require terminations to be reviewed by its Human Resources Department, its Legal Department or outside counsel?   Yes    No


13. Does the applicant have any written grievance or complaint procedures?   Yes    No


14. Does the applicant require its managers and supervisors to attend regular periodic training and education programs/seminars on employer-employee relations?   Yes    No


15. Does the applicant have a labor relations counsel?
   Yes    No


If yes, who is your labor relations counsel? 

Loss History and Insurance

1. During the last five years, have there been any wrongful termination, discrimination or sexual harassment claims made against the application or any of its directors, officers or employees?    Yes    No


If yes, provide Loss History (5 years) for all wrongful termination, discrimination and sexual harassment claims (complete form below).

Supplemental Form

Total Paid: 

Date/Description/ Damages/ Expenses:


2. Is the applicant aware of any facts, incidents, or circumstances which may result in claims being made against the company? If yes, please provide details.   Yes    No


Details:




3. Has the proposed coverage ever been purchased before, whether specifically or as a sub-section of addition to other coverage?
 Yes    No

If yes, give the retroactive date of the expiring insurance: 
If none, state “None.” 


4. Has any application for similar insurance or Lawyers Professional Liability coverage on behalf of the applicant, any partner, officer, director or employee of the applicant, or any of its predecessors in business been declined or canceled, renewal of such insurance refused, or any special terns imposed. If yes, provide full details.  Yes    No


Details:

The applicant warrants to the best of its knowledge and belief that the statements set forth herein are true and include all material information.

The applicant further warrants that if the information supplied on this applicant changes between the date of the application and the inception date of the policy period, it will immediately notify Amity Insurance Agency, Inc. of such change. Submitting this application on-line or the signing and faxing of this application does not bind the company to offer, nor the applicant to accept insurance, but it is agreed that this application shall be the basis of the insurance and will be attached and made a part of the policy should a policy be issued.

Note: Submitting form does not bind Amity Insurance, but indicates an interest in seeking information on estimated cost and coverage highlights.

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All Rights Reserved.
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Amity Insurance Agency, Inc., CORPORATE OFFICE
500 Victory Road, Marina Bay, North Quincy, MA 02171
Tel: 800-940-4010