Call Us (719) 488-5502 ☰ ˟
– Professional Liability you can trust
Logo
  • HOME
  • JOIN US
  • PRODUCTS
    • Insurance Agents
    • Miscellaneous Professional Liability
    • Cyber Liability Sign & Bind
    • Commercial Crime & EPLI
  • RISK MANAGEMENT
    • Risk Management
    • COVID Update April 2020
    • COVID Update May 2020
    • COVID Update July 2020
  • FORM WAREHOUSE
  • ABOUT US
    • About Us
    • Employee Directory
    • Refer a Friend
    • Privacy Policy
  • CONTACT
    • Contact Us
    • Join Our Newsletter
Home > Business > Employment Practices Liability Application
Secured by SSL

Employment Practices Liability Application


Fill out the following form as completely as possible. Once you have completed the form, click the Submit button to send your information. Your request will be handled promptly.

  • Personal Information
  • Employees and Locations
  • Description of Your Organization
  • Internal Controls
  • Financial Status (per latest FYE)
  • Loss History
First Name *
Last Name *
Street *
City *
State *
ZIP / Postal Code *
Primary Phone Number *
E-Mail Address *
Total Employees *
Independent Contractors *
Total Locations *
Date of Establishment *
/ /
Please describe the products or service or your predominant business or activity. *
Are bank accounts reconciled monthly? *

Are bank accounts reconciled by someone not authorized to deposit, withdraw or write checks? *

Are vouchers/supporting records stamped "PAID" when checks are signed? *

Do you maintain a list of approved vendors? *

Is countersignature of all checks required? *

If yes, above what amount?
Are Systems designed so that no single employee can control a transaction from beginning to end (e.g. approve a voucher, request and sign a check)? *

Do you screen your employees for prior acts of dishonesty? *

Are all shipping and receiving activities reconciled to all applicable sale/purchase orders? *

Do you have a system in place to prevent and detect payments to fictitious vendors? *

Is all purchasing centralized out of your main office? *

Is there personal supervision of business activities on a daily bass by an Owner? *

Does that person
Deposit all cash receipts? *

Sign or countersign all checks? *

Check petty cash periodically? *

Reconcile all bank accounts? *

Verify shipping and receiving activities? *

Review journal entries? *

is segregation of duties performed in the following?
Inventory management? *

Vendor approval? *

Oversight of check stock? *

Shipping and receiving? *

Annual Gross Assets
Total *
% change from prior year *
Annual Gross Sales
Total *
% change from prior year *
Net Profit
Total *
% change from prior year *
Net Worth
Total *
% change from prior year *
Enter all claims or occurrences that may give rise to claims for the prior 5 years*
Check if No Losses
Claims or Occurrence
Date of Occurence
/ /
Type/Description of Occurrence or Claim
Date of Claim
/ /
Amount Paid
Claim Status

Claims or Occurrence
Date of Occurence
/ /
Type/Description of Occurrence or Claim
Date of Claim
/ /
Amount Paid
Claim Status

Submission Validation
Required

Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

Per the terms of our online privacy policy we will not resell your information to any third-party.
Secured by SSL
Insurance Websites Designed and Hosted by Insurance Website Builder
Logo
Quick Links Home About Us Contact Us
Location 14241 Dallas Parkway, Ste 850, Dallas, TX 75254
© Copyright. All rights reserved. Powered by Insurance Website Builder