marrs maddocks || Employment Practices Liability Form

(ALL information on this form must be completed in order to process your request)

Desired Coverages

Desired Coverages Must be Checked to Process your Request:

Directors & Officers Liability	Employment Practices Liability
Fiduciary Liability

Company Name:

Address:

City:

State:

Zip Code:

Phone Number:

Fax Number:

Email:

Contact Name:

Nature of Operations:

Number of Employees:

Currently:

1 year ago:

2 years ago:

Company Information

About the Company

1.	Is the company a privately owned corporation or limited liability company (LLC)?	Yes	No
2.	Is all the common stock owned by directors or officers?	Yes	No
3.	Does the company, its major business partners (vendors, suppliers, etc.) and its pension and benefit plans have a Y2K compliance plan?	Yes	No
4.	Does the company use an employment manual?	Yes	No
5.	Do all employees get a copy of the employment manual?	Yes	No
6.	Is there a formal grievance procedure in place for employees to report employment problems?	Yes	No
7.	Does the company have a full time resource manager or person responsible for this duty?	Yes	No
8.	Respond YES if this statement is TRUE or NO if FALSE: "There have been no company-mandated staff reductions in the past 3 years and there are no plans for reductions over the next 2 years."	Yes	No
9.	Does the company sponsor only defined contribution plans or health and welfare benefit programs?	Yes	No
10.	If you answered YES to question number 9, please include the total assets of defined contribution plan: $
11.	Can the company confirm that it does not sponsor any defined benefit programs or ESOPs?	Yes	No

Litigation

1.	Respond YES if this statement is TRUE or NO if FALSE: "During the past three years, neither the company, its directors, officers or employees were/are defendants in litigation that has relevance to any coverages requested by this form (including EEOC proceedings, labor litigation, etc.)."	Yes	No
2.	If you answered NO to question number 11, please provide full details:

Past Coverage

1.	Does the company currently have any of these coverages?		Yes No
2.	If YES,
	D&O Insurer	Exp. Date (MM/DD/YY)	Premium $
	EPLI Insurer	Exp. Date (MM/DD/YY)	Premium $
	FDL Insurer	Exp. Date (MM/DD/YY)	Premium $
3.	If NO,
	Requested Limit	Requested Retention $

Financial Information