Metro North Chamber Program > Application > Metro North Chamber Online Application

Complete the following form to electronically submit your application for EPL Insurance. Once your form is submitted you will be redirected to our Thank You page as confirmation. If the form does not appear to submit, check that all fields with * are completed and click submit again.

Applicant's Name:

Address:

Phone:

Website address:

Date Established:

Nature of Your Business:

Number of Employees

Full Time:

Part Time:

Employees Terminated -

List below the number of employees terminated or demoted in the past twelve (12) months.

Voluntary:

Involuntary:

Laid Off:

Employee Reduction -

Do you plan to eliminate or change employment status during the next year (Yes/No)? If yes, provide an estimated number.

Business Reduction -

Does the Applicant anticipate any plant, facility, branch, office, or department closing, consolidation, reorganization or layoff within the next twenty-four (24) months (Yes/No)? if yes, provide details.

Human Resources -

Does Applicant have Policies & Procedures in place to (check if yes):

Provide a standard employment application for all applicants?

Address sexual harassment and unlawful discrimination in employment?

Discriminatory/Disciplinary Action -

Has Applicant been involved in (check if yes):

Discriminatory practice violation or litigation

Disciplinary Action by any regulatory agency or association, including the EEOC

If either of the above are checked, please explain below.

Claims Status -

Has the applicant given notice of claim or specific facts or circumstances which might give rise to a claim under any prior policies providing similar insurance? If yes, additional information may be required.

Yes
No

NOTE:

The next question is required if no previous Employment Practice Liability Insurance exists or a gap in coverage has occurred

No Person applying for this coverage is aware of any facts or circumstances which he or she has reason to presume might give rise to a future claim that would fall within the scope of any of the proposed coverages for which the Applicant has applied. Please state NONE or the details of any exceptions below.

Without prejudice to any other rights and remedies of the Underwriter, any claim arising from any claims, facts, circumstances or situations whether or not disclosed in the questions above is excluded from the proposed insurance.

Material Change

If there is any material change to the answers of this Application’s questions prior to the policy inception date, the Applicant must notify the Underwriter in writing. Any outstanding quotation may be modified or withdrawn.

WARNING:

ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND SUBJECTS SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES.

SIGNATURE

The Undersigned represents that to the best of his/her knowledge and belief the statements set forth herein are true. The undersigned further declares that any occurrence or event that takes place prior to the effective date of the insurance for which application is being made which may render inaccurate, untrue, or incomplete any statement made, will immediately be reported in writing to the Underwriter. The Underwriter may withdraw or modify any outstanding quotations and/or authorization or agreement to bind the insurance. The Underwriter is hereby authorized to make any investigation and inquiry in connection with the information, statements and disclosures provided in the Application. The signing of the application does not bind the Undersigned to purchase the insurance, nor does the review of this Application bind the insurance company to issue a policy. It is agreed that this Application shall be the basis of the contract should one be issued and for the purposes of this coverage this application will become a part of the policy and is incorporated by reference.

Businesses with 15 or less employees may select one of the deductible options below.

If your business does not fall within the specified criteria or you would like a different deductible, select “Other” and a Taggart Sales Representative will contact you with a specific quote.

$817 per year with a $5000 Deductible
$837 per year with a $2500 Deductible
Other

Name/Title:

Date

Thank-you for submitting your request online. We will contact you by the next business day. Please remember that no coverage is bound without written confirmation from your agent.

By clicking the Submit Button you are agreeing to the Terms & Conditions of doing business with our agency via the Internet.

If your form doesn’t appear to submit, verify all fields followed by * are completed, then click submit.

Submit Application