IA Near Me

Name	:	Denis Mehulic
License ID	:	0L58079
Phone	:	(408) 674-3569
Email	:	[email protected]
Address	:	ste 201 1095, San Jose, California, 95136

Applicant
General Information
Current EPLI Coverage
Miscellaneous
Finish

Applicant

Can you tell us about yourself?

First Name *

Last Name *

Email *

Phone *

General Information

Business Name

Business Address

Address *

City *

State *

Zipcode *

Nature of Business

Year Established

Annual Revenues

Total number of employees

( including Partners, Directors and Officers, at all locations)

Full Time Employee

Part Time Employee

Temp/Leased Employee

Seasonal Employee

Contract Employee

Does the applicant have union employees?

Yes

Terminations / Layoffs

Number of Involuntary Terminations in past 12 months, if any:

Any anticipated/pending layoffs, or any layoffs within the last 12 months?

Does the Insured consult with employment counsel prior to all terminations?

Yes

Does the Insured provide an Employee Handbook to it’s employees?

Yes

Current EPLI Coverage

Do you currently have active EPLI coverage?

Yes

EPLI Coverage

Current policy expiration date:

Has any EPL carrier ever canceled/non-renewed you?

Yes

What are the limits?

What are the deductible?

What are the premium?

P&P/Continuity dates if prior coverage:

Miscellaneous

Any Merger & Acquisition activity?

Yes

Do you use HR Personnel, Anti-Harassment/Discrimination policies?

Yes

Have you had any claims and/or allegations of inappropriate employment acts, discrimination, wrongful termination andharassment in the last 5 years?

Yes

Are you aware of any claim(s), fact(s), circumstance(s), situation(s), transaction(s) or event(s) as of the date of thisapplication is signed, which could reasonably give rise to a claim and/or allegation or any reasonable way to foresee thatone may be brought?

Yes

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