BUSINESS OWNERS PROGRAM

Employment Practices Liability Quote Request

1) GENERAL INFO
CITY
STATE
ZIP
DAYTIME
FAX
2) Current number of Employees, including owners, partners, officers and directors for the Headquarter state.
FULL-TIME
PART TIME
TEMPORARY
SEASONAL
FULL-TIME
PART TIME
TEMPORARY
SEASONAL
3) Total number of persons employed by the applicant in each of the last 3 years (all locations).
YEAR
# OF EMPLOYEES
YEAR
# OF EMPLOYEES
YEAR
# OF EMPLOYEES
4) Total Number of employees that were terminated by the business and the total number of employees that voluntarily left their employment in the past three years (all locations)
YEAR
TERMINATED
VOLUNTARILY LEFT
YEAR
TERMINATED
VOLUNTARILY LEFT
YEAR
TERMINATED
VOLUNTARILY LEFT
5)
YEAR
TERMINATED
VOLUNTARILY LEFT
YEAR
TERMINATED
VOLUNTARILY LEFT
YEAR
TERMINATED
VOLUNTARILY LEFT
Are the following published and distributed to all employees:
Please indicate whether the following optional coverages are desired:
Leased Workers
Independent Contractors
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