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SHORT-FORM APPLICATION FOR EMPLOYMENT PRACTICES LIABILITY INSURANCE

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SHORT-FORM APPLICATION FOR EMPLOYMENT PRACTICES LIABILITY INSURANCE Powered By Docstoc
					                                             BERNAU & JONES
                                               INSURANCE SERVICES
                          1330 BROADWAY, SUITE 415 OAKLAND, CA 94612
              PHONE NO.: (510) 208-6625 LICENSE NO.: 0831451 FAX NO.: (510) 272-9768


      SHORT-FORM APPLICATION FOR EMPLOYMENT PRACTICES LIABILITY INSURANCE
                         FOR PREMIUM INDICATIONS ONLY


1. Full legal name of proposed Name Insured:




2. Principal place of business (location):

                                                                                  Telephone


Full-time Employees:                Part-time Employees:________(Note: Include all temporary, leased, and
seasonal employees, as well as officers, owners & partners active in the business, including all affiliates.

If there are currently no seasonal employees, show here average number of such employees hired annually)
Full-time Employees: __________Part-time Employees: ________

3. Description of primary business activities & main SIC codes:



4. Show all other insured locations, including addresses and corporate names:

Name        Relationship            Location         Complete Address         Full-time Empl. Part-time
Empl.




5. How many people have been involuntarily terminated over the last 3 years?

6. Annual Sales: $_________________Annual payroll:

7. Do you have a personnel or human resources department

8. Do you intend to make any acquisitions or close any facilities within the next year?

9. Are you aware of any present situation that may result in a claim in the next year?




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10. Of the total number of EEOC/state agency charges filed against any insured over the last seven years,
       indicate the primary allegations as follows:


       LOCATION #                   1             2               3            4     _____
Racial Discrimination
______________________________________________________________________________________
Age Discrimination
______________________________________________________________________________________
Religious Discrimination
______________________________________________________________________________________
Other Ethnic Discrimination
______________________________________________________________________________________
Fair Labor Standards Act
______________________________________________________________________________________
Gender Discrimination/
Sexual Harassment
______________________________________________________________________________________
Violation of
Disabilities Act__________________________________________________________________________
All others
______________________________________________________________________________________


11. With respect to litigated cases (including wrongful termination suits under state law other than
antidiscrimination law) and EEOC/state agency charges over the last seven years for which
settlement was or may be paid, please provide the following information, which must be currently valued:



        CLAIM #                                   1               2           3                4__________

Date of Occurrence______________________________________________________________________

Claimant______________________________________________________________________________

Allegation_____________________________________________________________________________

Damages Paid_________________________________________________________________________

Damages Reserved_____________________________________________________________________

Legal Expense Paid_____________________________________________________________________

Legal Expense Reserved_________________________________________________________________




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