Basic Info Name of Firm: Name of Contact: Email: Phone: Fax: Business address: City: State: AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWashington, DCWest VirginiaWisconsinWyoming Zip: Staff Size a) Number of full-time employees: b) Number of part-time employees: c) Number of seasonal employees: d) Number of temporary employees: Est. Annual Billings: Has the prospective applicant carried continuous employment practices liability insurance during the past five years? No Yes Current professional liability insurance coverage Insurance Company Limits of Liability Deductible Annual Premium Date Current Policy Expires Retroactive/Prior Acts Date Desired Limit of Liability 250k--750k500k--500k1000k--1000k1000k--2000k1000k--3000k 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. 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 Do you wish to be added to CPA Mutual's E-mail list: Yes No
