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CGA Employment Practices Insurance Application
We would like to provide you with a free, no-obligation quote. Please provide as much information possible for the most accurate quote. This information will be kept confidential and will be used for quote purposes only.

Submitting Information

Business Name:
Contact Name:
Street Address:
City:	State: ZIP:
County:	Email:
Business Phone:	Fax:

Application Information Section

Name:
Business Name:
Address:
City:
State:
Zip Code:
Phone Number:
Fax Number:
E-Mail Address:

Location/Additional Information Section
Additional Business Address	F/T Employees	P/T Employees	Seasonal
Loc #1: Same Address As Above
Loc #2:
Loc #3:

Underwriting Information
Please Describe the Nature of Your Business
Type of Ownership:
Years of Experience:
Number of employees under age 40:
Number of employees over age 40:
Number of employees by salary range (under $25,000 year):
Number of employees by salary range ($25,000-$75,000 year):
Number of employees by salary range (over $75,000 year):
Number of employees that left the company (last year):
Number of employees that left the company (year before last):
How Many Years Have You Operated This Business:
Business License Number:
License Type:
This Years Estimated Gross Receipts:
Last Years Gross Receipts:
Year Before Last Gross Receipts:
Is This Business Open 24 Hours A Day?	yes no
Are you aware of any claim situation not filed?	yes no
Any inquiries from the National Labor Relations Board?	yes no
Any inquiries from the Equal Employment Opportunity Commission?	yes no
Any inquiries from the Fair Labor Standards Enforcement Act? ?	yes no
Any inquiries from the Civil Rights Act of 1991?	yes no
Any inquiries from the U.S. Department of Labor?	yes no
Any inquiries from any state or local government agency?	yes no
Any inquiries from the Age Discrimination Employment Act?	yes no
Any inquiries from the Americans with Disabilities Act?	yes no
Do you have Federal contracts or serve as a subcontractor on contracts over $50,000 per year?	yes no
Has there been a Company merger within the last 24 months?	yes no
Is a Company merger expected within the next 24 months?	yes no
Do you anticipate layoffs within the next 24 months?	yes no
Do you use an employment application for all applicants for hire?	yes no
Do you have an affirmative action plan?	yes no
Has your affirmative action plan been updated within the last 12 months?	yes no
Do you have a written policy regarding harassment?	yes no
Do you have a written pay raise program for your company?	yes no
Do you have an established internal dispute resolution or grievance process?	yes no
Do you have a written disciplinary process?	yes no
Do you have a performance appraisal process?	yes no
Do you evaluate all employees annually?	yes no
Are employee terminations reviewed by Human Resources?	yes no
Are employee terminations reviewed by legal counsel?	yes no
Do you have written policies for Americans with Disabilities Act?	yes no

Loss Information Section
Describe any Losses-Claims in the last 5 years related to allegations of wrongful termination, discrimination or sexual harassment

Coverage Section
Liability Limits Requested:
Deductible Requested:
Current Insurance Company:
Current Annual Premium:
Any additional Information / Comment ?