CPA Mutual Insurance Company of America Risk Retention Group

Employment Practices Liability Quick Quote

Name of Firm

Name of Contact

Business address

City

State ZIP

Phone

Fax

Email

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Staff Size

a)Number of full-time employees

b)Number of part-time employees

c)Number of seasonal employees

d)Number of temporary employees

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Est. Annual Billings

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Has the prospective applicant carried continuous employment practices liability insurance during the past five years?

Yes
No

a) Current professional liability insurance coverage
Insurance Company:

Limits of Liability:

Deductible:

Annual Premium:


b) Date Current Policy Expires
/ /

c) Retroactive/Prior Acts Date
/ /

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Desired Limit of Liability

$250,000/$750,000 $500,000/$500,000 $1,000,000/$1,000,000 $1,000,000/$2,000,000 $1,000,000/$3,000,000

Deductible Requested

$2,500
$5,000
$10,000
Other

$1,000 or $2,500 deductible available only with $250,000 or $500,000 limit of liability.
Other deductibles available upon request.

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Other Info

Does applicant publish and employee's manual?
Yes No

If so, Is it distributed to all employees?
Yes No

Has the applicant implemented or adopted anti-sexual harassment policies/procedures?
Yes No

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

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Validation Test

Please enter the characters you see in the image above (case sensitive):

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Please check your information carefully.

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