| Please
note: All fields in this form
are required. |
| XXXApplicant
Information |
| |
|
PROPOSED
NAMED INSURED:
|
|
| STREET: |
|
| CITY: |
|
| STATE: |
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| ZIP: |
|
| COUNTRY: |
|
| PHONE: |
|
| FAX:
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| EMAIL:
|
|
| |
| XXXProposed
Additional Insures |
| |
| DOES
APPLICANT HAVE A FULL TIME PERSONNEL DEPARTMENT? |
|
|
o
Yes
No |
| |
NUMBER
OF EMPLOYEES UNDER EMPLOYEE BENEFIT PROGRAMS ADMINISTERED IN THE
U.S.,
IT'S TERRITORIES OR CANADA? |
|
U.S.:
|
o
|
|
U.S.
TERRITORIES: |
o
|
| CANADA:
|
o
|
| |
EMPLOYEE BENEFIT PROGRAMS WHICH ARE AUTOMATICALLY COVERED WITHOUT
BEING SPECIFICALLY
LISTED BY THE APPLICANT ARE:
Group
Life Insurance, Group Accident or Health Insurance, Workers
Compensation, Profit Sharing Plans, Unemployment Insurance,
Pension Plans, Social Security Benefits, Employee Stock Subscription
Plans, and Disability Benefits Insurance
|
| |
LIST
BELOW ANY OTHER TYPES OF BENEFIT PROGRAMS THE APPLICANT WANTS
US TO CONSIDER FOR
INCLUSION UNDER THIS INSURANCE: |
| LIST
|
|
| |
ON
PROGRAMS PERMITTING EMPLOYEES AN OPTION TO ENROLL OR NOT TO ENROLL,
DOES THE APPLICANT REQUIRE
A SIGNED ACCEPTANCE, REJECTION, OR WAIVER
FROM EACH EMPLOYEE? |
|
|
o
Yes
No |
| |
| IF
YES, IS THE SIGNED ACCEPTANCE, REJECTION, OR WAIVER RETAINED IN
THE EMPLOYEES PERSONNEL FILE? |
|
|
o
Yes
No |
| |
| IS
A BENEFIT BROCHURE OR WRITTEN EXPLANATION OF THE EMPLOYEE BENEFITS
PROGRAM GIVEN TO EACH EMPLOYEE? |
|
|
o
Yes
No |
| |
| ARE
ANY PLANS JOINTLY ARRANGED BY MANAGEMENT AND EMPLOYEES? |
|
|
o
Yes
No |
| |
| IS
THERE A RECORD KEPT AS TO EMPLOYEE'S ACCEPTANCE OR REJECTION OF
ANY ONE OR ALL OF THE BENIFITS? |
|
|
o
Yes
No |
| |
| HAS
ANY ERRORS OR OMISSION LOSS EVER BEEN SUSTAINED OR IS ANY PENDING
AGAINST THE APPLICANT? |
|
|
o
Yes
No
|
| |
| IF
YES, PLEASE GIVE DETAILS: |
|
|
|
| |
| HAS
ANY OCCURRENCE TAKEN PLACE IN THE PAST THAT IS LIKELY TO GIVE
RISE TO A CLAIM? |
|
|
o
Yes
No
|
| |
| IF
YES, PLEASE GIVE DETAILS: |
|
|
|
| |
| NUMBER
OF BRANCHES, OTHER BUSINESS LOCATIONS: |
|
|
|
| HOW
ARE EMPLOYEES IN BRANCHES AND OTHER LOCATIONS ADVISED OF BENIFITS: |
| DESCRIBE
|
|
| |
| XXXLimits
of Liability Requested
|
| |
| EACH
"NEGLIGENT ACT":
|
$
|
| AGGREGATE:
|
$
|
| |
| XXXPolicy
Period |
| |
PRESENT
OR
PRIOR CARRIER: |
o
|
|
POLICY
PERIOD : |
o FROM:
TO:
(mm/dd/yyyy)
|
|
POLICY
NUMBER : |
o
#
|
|
POLICY
TERM : |
o
(Years)
|
| |
| XXXAgent
or Broker Information |
| |
| CONTACT
NAME: |
|
| COMPANY
NAME: |
|
| STREET: |
|
| CITY: |
|
| STATE: |
|
| ZIP: |
|
| COUNTRY: |
|
| PHONE
NUMBER : |
|
| EMAIL
ADDRESS: |
|
| |
| Submit
Form: |
|
|
| Reset
Form: |
|
|