IA Near Me

Name	:	Steven Longenecker
License ID	:	Various
Phone	:	(303) 808-9351
Email	:	[email protected]
Address	:	2362 Eagleview Circle, Longmont, Colorado, 80504

Applicant
Business
Human Resource
Policy
Losses
Coverage
Miscellaneous
Finish

Applicant

First Name *

Last Name *

Where should we send your quote?

Email *

Phone *

Please fill all the mandatory questions.

Business

Business Info

Business / Company Name *

Founding Date *

DBA (If Applicable)

FEIN # (If Applicable)

Organization Type

Business Address

Address *

City *

State *

Zip Code *

Type of Business *

Specify business *

Employment

Employees

Full-Time Employees

Part-Time Employees

Volunteers

Independent Contractors

Salary

Employees Being Compensated Less Than $50,000 Annually *

Employees Being Compensated Less Than $100,000 Annually *

What Percentage of the Applicant's Employee Base is Exempt *

What Percentage of the Applicant's Employee Base is Nonexempt *

Within The Past 24 Months Has The Applicant Or Outside Employment Counsel Completed An Audit Regarding The Payment Of Wages, Including Equal Pay And Overtime Pay?

Yes

Within The Past 24 Months Has The Applicant Or Outside Employment Counsel Completed An Audit Regarding The Classification Of Individuals As Exempt V. Nonexempt Employees Or As Independent Contractors?

Yes

Terminations

2021

Number of Terminations (Voluntary)

Number of Terminations (Involuntary)

Number of Terminations (Layoffs/Downsizing)

2020

Number of Terminations (Voluntary)

Number of Terminations (Involuntary)

Number of Terminations (Layoffs/Downsizing)

2019

Number of Terminations (Voluntary)

Number of Terminations (Involuntary)

Number of Terminations (Layoffs/Downsizing)

Within The Past 24 Months How Many Officers Have Been Involuntarily Terminated Or Laid Off?

Does The Applicant Provide Severance Packages To Terminated Or Laid Off Employees?

Yes

Does the severance agreement include a waiver or release of an employee’s rights to bring claim against the Applicant?

Yes

Prior to employee terminations does the Applicant consult with the HR?

Yes

Prior to employee terminations does the Applicant consult with an Attorney with experience in Employement Law?

Yes

Additionals

Is requested coverage to include entities that are more than 50% owned, or joint ventures that are at least 50% owned, by the Applicant, either directly or indirectly through one or more subsidiaries?

Yes

In the next 12 months (or during the past 24 months) is the Applicant contemplating (or has the Applicant completed or been in the process of completing) the following:

Any Actual Or Proposed Merger, Acquisition, Or Divestiture?

Yes

Any Branch, Location, Facility, Office, Or Subsidiary Closings, Consolidations Or Layoffs?

Yes

Please fill all the mandatory questions.

Human Resource

Does the Applicant have a Human Resources Department?

Yes

Number of Human Resource Employees

Are All Prospective Employees Required To Complete A Uniform Employment Application Prior To Hire?

Yes

Does The Applicant Have An Employee Handbook That Is Distributed To All Employees?

Yes

Are Employees Required To Acknowledge, By Signature,Receipt Of Such Employee Handbook?

Yes

Does The Employment Application Or Employee Handbook Contain An “Employment At Will” Statement?

Yes

Formal Written Policy

Discrimination

Yes

Sexual And Other Workplace Harassment

Yes

Equal Employment Opportunity

Yes

FMLA

Yes

Disabled Employees And Accommodations

Yes

Retaliation

Yes

Reporting, Investigating And Resolving Employee Complaints

Yes

Employee Discipline

Yes

Written Performance Appraisals/Reviews

Yes

Salary Administration

Yes

Hiring / Interviewing

Yes

Discharge / Termination

Yes

Do employees Sign and Acknowledged Receipt the ff:

Discrimination

Yes

Sexual And Other Workplace Harassment

Yes

Equal Employment Opportunity

Yes

FMLA

Yes

Disabled Employees And Accommodations

Yes

Retaliation

Yes

Reporting, Investigating And Resolving Employee Complaints

Yes

Employee Discipline

Yes

Written Performance Appraisals/Reviews

Yes

Salary Administration

Yes

Hiring / Interviewing

Yes

Discharge / Termination

Yes

Status regarding employment practices policies

procedures and employee conduct

Are The Applicant’s Employment Practices Policies, Procedures And Employee Handbook Periodically Reviewed By An Attorney With Experience In Employment Law?

Yes

Does The Applicant Have Written Policies Or Procedures Outlining Employee Conduct When Dealing With The General Public, Customers, Clients, Vendors, Or Other Third Parties?

Yes

Does The Applicant Have Written Policies Or Procedures For Dealing With Complaints From The General Public, Customers, Clients, Vendors, Or Other Third Parties For Issues Involving Harassment Or Discrimination?

Yes

Does The Applicant Conduct Human Resources Training On Guidelines, Policies And Procedures For All Individuals Who Handle Human Resources Functions?

Yes

Does The Applicant Conduct Training For Employees On Issues Of Discrimination And Sexual And Other Workplace Harassment?

Yes

If the Applicant is a federal contractor subject to the OFCCP, has the Applicant been subject to a compliance evaluation or investigation in the last 3 years?

Yes

Please fill all the mandatory questions.

Policy

Prior / Existing Carrier

Do you have any prior carrier?

Yes

Name of Carrier *

Expiring Limits

Expiring Limit

Expiring Retention

Have You Had Any Losses In The Last Three Years?

Yes

Please fill all the mandatory questions.

Losses

Loss 1

Losses / Claim

Nature of Loss / Claim *

Date of Loss / Claim

Amount Paid for Defence *

Amount Sought Or Paid For Damages *

Covered By Insurance?

Yes

Details of Loss / Claim

Please fill all the mandatory questions.

Coverage

Requesting Limits

Requested Limit

Requested Retention

Requested Effective Date

Insurance Terms

What Is The Applicant’s Preference For Defense Coverage?

Duty To Defend

Reimbursement

Is Coverage Requested For Third Party Claims

Yes

Is Third Party Coverage Currently Included?

Yes

Is the Applicant, or any person proposed for this insurance aware of any fact, circumstance, situation, event or act that reasonably could give rise to a claim against them under Third Party coverage for which the Applicant is applying?

Yes

Please fill all the mandatory questions.

Miscellaneous

Is this a Subsidiary?

Yes

Has other Subsidiaries?

Yes

Business Has Trust

Yes

Do any of the following apply to your business?

Draws Plans, Designs, or Specifications

Using or Storing Explosives

Excavation, Tunneling, or Earth Moving

Lease Equipment to Others

Install, Service, or Demo Products

Distribute, Sell, or Use Foreign Products

Research, Plan, or Develop Products

Works on Aircraft/Space Products

Creates Warranties and Agreements

Rent Machinery to Others

Leases Employees to Other Businesses

N/A

Any Exposure to Flammables, Explosives, or Chemicals?

Yes

Please fill all the mandatory questions.

EPLI

Applicant

Where should we send your quote?

Business

Business Info

Business Address

Employment

Employees

Salary

Terminations

2021

2020

2019

Additionals

In the next 12 months (or during the past 24 months) is the Applicant contemplating (or has the Applicant completed or been in the process of completing) the following:

Human Resource

Formal Written Policy

Do employees Sign and Acknowledged Receipt the ff:

Status regarding employment practices policies

Policy

Prior / Existing Carrier

Expiring Limits

Losses

Loss 1

Losses / Claim

Coverage

Requesting Limits

Insurance Terms

Miscellaneous

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