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BUSINESS EMPLOYMENT PRACTICES INSURANCE QUOTE REQUEST
Complete the following information if you would like to obtain a Business Employment Practices Insurance quote. Please understand this is not an application. An application will be sent to you if coverage is desired.
All information provided on this information sheet is confidential and will be used solely for the purpose of developing a quote for you.
Personal Information
What is your name?
Last
First
Middle
What is your business name?
Business Name
What is your address?
Street
City
State
Zip
What is your telephone number?
Home
Business
What is your fax number?
Fax
What is your email address?
Email
Location Detail Information
How many employees are at Location #1 (address above)?
Full Time Employees
Part Time Employees
Seasonal Employees
What is the address of Location #2?
Location #2 Street
Location #2 City
Location #2 State
Location #2 Zip
How many employees are at Location #2 (address above)?
Full Time Employees
Part Time Employees
Seasonal Employees
What is the address of Location #3?
Location #3 Street
Location #3 City
Location #3 State
Location #3 Zip
How many employees are at Location #3 (address above)?
Full Time Employees
Part Time Employees
Seasonal Employees
Underwriting Information
What is the nature of your business?
Nature of Business
Is the business a corporation, partnership or sole proprietorship?
Corporation
Partnership
Sole Proprietorship
How many owners?
Number of Owners
How many employees are under age 40?
Number of Employees under age 40
How many employees are salaried under $25,000 year?
Salaries Under $25,000
How many employees are salaried $25,000 - $75,000 year?
Salaries $25,000 - $75,000
How many employees are salaried over $75,000 year?
Salaries over $75,000
How many employees left the company last year?
Number of Employees that Left Last Year
What was the total annual gross last year?
Total Annual Gross Receipts
What is the business license number?
Business License Number
What is the license type?
License Type
How many years have you operated this business?
Years Operated Business
What were the year before last gross receipts?
Year Before Last Gross
Is this business open 24 hours a day
Open 24 Hours
Yes No
Are you aware of any claim situation not filed?
Claim Situation
Yes No
Are there any inquiries from the National Labor Relations Board?
Inquiries from National Labor Relations Board
Yes No
Are there any inquiries from the Equal Employment Opportunity Commission?
Inquiries Equal Employment Opportunity Commission
Yes No
Are there any inquiries from the Fair Labor Standards Enforcement Act?
Inquiries Fair Labor Standards Enforcement Act
Yes No
Are there any inquiries from the Civil Rights Act of 1991?
Inquiries Civil Rights Act of 1991
Yes No
Are there any inquiries from the U.S. Department of Labor?
Inquiries U.S. Department of Labor
Yes No
Are there any inquiries from any state or local government agency?
Any State or Local Government Agency
Yes No
Are there any inquiries from the Age Discrimination Employment Act?
Inquiries Age Discrimination Employment Act
Yes No
Are there any inquiries from the Americans with Disabilities Act?
Inquiries Americans with Disabilities Act
Yes No
Do you have Federal contracts or serve as a subcontractor on contracts over $50,000 per year?
Federal Contracts
Yes No
Has there been a company merger within the last 24 months?
Company Merger
Yes No
Do you anticipate layoffs within the next 24 months?
Layoffs
Yes No
Do you use an employment application for all applicants for hire?
Employment Application Used
Yes No
Do you have an affirmative action plan?
Affirmative Action Plan
Yes No
Has your affirmative action plan been updated within the last 12 months?
Affirmative Action Plan Updated
Yes No
Do you have a written policy regarding harassment?
Written Policy Regarding Harassment
Yes No
Do you have a written pay raise program for your company?
Written Pay Raise Program
Yes No
Do you have an established internal dispute resolution or grievance process?
Internal Dispute Resolution
Yes No
Do you have a written disciplinary process?
Written Disciplinary Process
Yes No
Do you have a performance appraisal process?
Performance Appraisal Process
Yes No
Do you evaluate all employees annually?
Evaluate All Employees Annually
Yes No
Are employee terminations reviewed by Human Resources?
Terminations Reviewed by Human Resources
Yes No
Are employee terminations reviewed by legal counsel?
Terminations Reviewed by Legal Counsel
Yes No
Do you have written policies for Americans with Disabilities Act?
Americans with Disabilities Act Policies
Yes No
Claims Information
Where there any losses or claims in the last 5 years related to allegations of wrongful termination, discrimination or sexual harassment?
Losses - Claims
Yes No
If yes, what is the date, amount paid and description of each loss or claim?
Coverage Information
What is the current insurance company?
How much are you paying now?
Amount Current Coverage
What is the liability limit requested?
Liability Limit
Are there any questions, comments or additional coverage required?
Questions, Comments or Additional Coverage
Best Time to Contact You
Please let us know the best time to call and discuss your quote.
Morning
Afternoon
Evening
Anytime
Or specify other:
     
 
V. H. JR., & ASSOCIATES, INC.

1435 W Busch Blvd. Ste. D | Tampa, FL 33612
Phone 813-931-5546
Fax 813-931-9137
 
 
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