May 19, 2013
Ten Eyck Group

Employment Practices Liability

Non-Bindable Indication Questionnaire
Applicant Information
Name
Address
City
State
Zip
Phone
Email
Applicant Information
Nature of Business
Year Business Established
SIC Code
Currently Insured? Yes  No
Current Carrier (If answered Yes above please answer this question)
Current Limit (If answered Yes above please answer this question)
Current Deductible (If answered Yes above please answer this question)
Current Premium (If answered Yes above please answer this question)
Current Renewal Date (If answered Yes above please answer this question)
Manager/Supervisor Training? Yes  No ?
Employees
Number of Full- Time
Number of Part-Time
Number of Temp/Agency
Number of Seasonal
Salary Ranger $0-$25,000
$25,001 - $50,000
$50,001 - $100,000
$100,001 - $250,000
$250,000+
Loss Information
Human Resource Department Yes  No ?
Employement Applications Yes  No ?
Employee Handbook
Please answer the questions that apply
Do you publish an Employee Handbook? Yes  No
Do you distribute it to all employees? Yes  No
Do you require all employees to sign off that they have received the handbook? Yes  No
Does the Handbook contain the following policies? (Check all that apply) Sexual Harassment
Equal Employment Opportunity
Americans with Disabilities Act
Open door/Grievance/Complaint
"At-Will" employment wording
Family & Medical Leave Act
Pregnancy Leave
Do you do performance evaluations for all employees? Yes  No
Are there job descriptions written in the handbook? Yes  No
Do you require all terminations be reviewed by Upper Management or owners
HR Department
In-house counsel
Outside Legal Councel experience in employment law
Legal Counsel
Legal Counsel Consultation Yes  No ?
Name of Firm (If yes above please answer this question)
Name of Counsel (If yes above please answer this question)
City of Firm (If yes above please answer this question)
State of Firm (If yes above please answer this question)
* = Required Field
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