Agent Info:
Name : Jen K
License ID : 9793086
Phone : (949) 258-9835
Email : [email protected]
Address : 2072 Orchard Drive, Newport Beach, California, 92660

EPLI

  • 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 *

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?

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:

Please fill all the mandatory questions.

Human Resource

Number of Human Resource Employees

Formal Written Policy

Do employees Sign and Acknowledged Receipt the ff:

Status regarding employment practices policies

procedures and employee conduct

Please fill all the mandatory questions.

Policy

Prior / Existing Carrier

Name of Carrier *
Expiring Limits
Expiring Limit
Expiring Retention

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 *
Details of Loss /​ Claim

Please fill all the mandatory questions.

Coverage

Requesting Limits

Requested Limit
Requested Retention
Requested Effective Date

Insurance Terms

Please fill all the mandatory questions.

Miscellaneous

Please fill all the mandatory questions.



Your details has been submitted successfully.