Adam Miller Agency LLC - Employment Practices Liability Insurance Quote Request

Employment Practices Liability Insurance Quote Request Form

Please fill in the information below to receive a Employment Practices Liability Insurance quote for Connecticut.

Our insurance agents will provide a quote for insurance as soon as possible.

Business name, contact name and full address including zip code are required. All other information is optional although the more you provide, the more accurate the quote.

For fastest response please include email address.

Business Name: 
Address:        
               
City:           CT
Zip Code:      
Phone #:          
Fax #:         

Contact Name:  
Address:        
               
City:           CT
Zip Code:      
Phone #:          
Email:         

Description of Business Operations:


Years in Business: 

Total # of Employees: 
Full Time - 		  
Part Time - 		  
Seasonal  - 		  

% Employees Earning Over $50,000:    Over $100,000: 

Estimated Annual Sales for the Next Fiscal Year: 

Average Annual Employee Turnover for the Past 3 Years: 

Does the Business have an HR or Personnel Department? Yes No

If No, please provide the name & title of the person handling 
this function: 

Name:   
Title: 

Does the Business require job applicants to complete an Employment 
Application? Yes No

Does the Business have an Employee Handbook? Yes No

If Yes, when was the Employee Handbook last updated? 

Do the present Business Plans call for a Reduction in Employee Force 
by more than 10% during the next 12 months? Yes No

Does the Business currently carry Employee Practices Liability 
coverage? Yes No

Claim History (Last 5 years for Wrongful Termination, Discrimination,
Sexual Harassment or any other employee practices, including EEOC
or other Administrative Agency Hearings):

Year	# of Claims	Details of Claims/ Allegations	Total Settlement Paid	Total Legal Expenses Paid

Additional Information or Comments

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The resulting quote does not constitute coverage and is subject to
verification by the insurance company.