Employment Practices Liability (EPL) Quick-Quote Form

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* 1. Legal Business Name:
Including DBA names.

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* 2. Legal Structure

Sole proprietor

Partnership

Corporation

LLC

PLLC

Other (please specify)

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* 3. Practice Type

Small Animal Exclusive

Predominately Small Animal

Predominately Large/Food Animal

Equine Exclusive

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* 4. Practice Owner's Name:

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* 5. Insurance Contact Name:
If different from practice owner.

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* 6. Mailing Address:

Address

City

State

Zip Code

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* 7. Physical Address

Address

City

State

Zip Code

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* 8. Telephone Number:

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* 9. Email Address:
For security reasons, please provide a private email address not shared by multiple employees.

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* 10. Years in Business:

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* 11. Number of Locations:

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* 12. Estimated total assets ($):

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* 13. Employee Count:

Current

1 Year Ago

Full Time

Part Time

Leased/Loaned

Seasonal/Temporary

Independent Contractors

Volunteers

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* 14. Total Current Number of Employees with compensation (including bonuses) in the following categories:

Less than $50,000

$50,000 to $100,000

$101,000 to $250,000

Greater than $250,000

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* 15. Number of Employees for annual income:

Under $50,000

Between $50,000 - $100,000

Over $100,000

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* 16. How many Employees, including Veterinarians, have been involuntarily terminated in the past 12 months?

Employees

Veterinarians

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* 17. For each of the most recent years, how many Employees have voluntarily terminated?

Year

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* 18. Expiration date of your current employment practices liability policy written through another agent or program.
If no policy exists, please enter the desired effective date of a new policy.

Date

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* 19. Have you completed any of the following in the past eighteen (18) months? Are you in the process or do you plan to complete any of the following during the next twelve (12) months?

	True	False
Our practice is not contemplating any layoffs, staff reductions, or facility closings that will affect more than 25% of the workforce.	Our practice is not contemplating any layoffs, staff reductions, or facility closings that will affect more than 25% of the workforce. True	Our practice is not contemplating any layoffs, staff reductions, or facility closings that will affect more than 25% of the workforce. False
Our practice has written guidelines or procedures addressing discrimination, sexual harassment, and employee complaints that are available to our employees.	Our practice has written guidelines or procedures addressing discrimination, sexual harassment, and employee complaints that are available to our employees. True	Our practice has written guidelines or procedures addressing discrimination, sexual harassment, and employee complaints that are available to our employees. False
Our practice is not a subsidiary or U.S. division of a foreign parent company.	Our practice is not a subsidiary or U.S. division of a foreign parent company. True	Our practice is not a subsidiary or U.S. division of a foreign parent company. False
During the past three (3) years, our practice has had fewer than three (3) EPL incidents and the total amount paid or reserved on all litigation was less than $50,000.	During the past three (3) years, our practice has had fewer than three (3) EPL incidents and the total amount paid or reserved on all litigation was less than $50,000. True	During the past three (3) years, our practice has had fewer than three (3) EPL incidents and the total amount paid or reserved on all litigation was less than $50,000. False

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* 1. Legal Business Name:Including DBA names.

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* 2. Legal Structure

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* 3. Practice Type

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* 4. Practice Owner's Name:

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* 5. Insurance Contact Name:If different from practice owner.

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* 6. Mailing Address:

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* 7. Physical Address

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* 8. Telephone Number:

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* 9. Email Address:For security reasons, please provide a private email address not shared by multiple employees.

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* 10. Years in Business:

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* 11. Number of Locations:

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* 12. Estimated total assets ($):

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* 13. Employee Count:

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* 14. Total Current Number of Employees with compensation (including bonuses) in the following categories:

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* 15. Number of Employees for annual income:

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* 16. How many Employees, including Veterinarians, have been involuntarily terminated in the past 12 months?

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* 17. For each of the most recent years, how many Employees have voluntarily terminated?

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* 18. Expiration date of your current employment practices liability policy written through another agent or program.If no policy exists, please enter the desired effective date of a new policy.

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* 19. Have you completed any of the following in the past eighteen (18) months? Are you in the process or do you plan to complete any of the following during the next twelve (12) months?

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* 20. If you answered false to any of the questions above, please provide a brief explanation.

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* 21. Have you had any EPL claims in the past 3 years?

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* 22. Do you have knowledge of any pending or potential lawsuit?

* 1. Legal Business Name:
Including DBA names.

* 5. Insurance Contact Name:
If different from practice owner.

* 9. Email Address:
For security reasons, please provide a private email address not shared by multiple employees.

* 18. Expiration date of your current employment practices liability policy written through another agent or program.
If no policy exists, please enter the desired effective date of a new policy.