EMPLOYMENT PRACTICES LIABILITY INSURANCE APPLICATION

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Deerfield Insurance Company Agent Name

Evanston Insurance Company Agent Street

Essex Insurance Company Agent City, State, Zip

Markel American Insurance Company

Markel Insurance Company

Associated International Insurance Company

EMPLOYMENT PRACTICES LIABILITY INSURANCE APPLICATION

(To be attached to ACORD or Program applications.)

NOTICE: THE EMPLOYMENT PRACTICES LIABILITY COVERAGE ENDORSEMENT PROVIDES CLAIMS MADE COVERAGE,

WHICH APPLIES ONLY TO CLAIMS FIRST MADE AND REPORTED DURING THE POLICY PERIOD OR ANY APPLICABLE

EXTENDED REPORTING PERIOD. THE LIMIT OF LIABILITY TO PAY JUDGEMENTS OR SETTLEMENTS WILL BE REDUCED AND

MAY BE EXHAUSTED BY AMOUNTS INCURRED FOR DEFENSE COSTS. AMOUNTS INCURRED FOR DEFENSE COSTS WILL BE

APPLIED AGAINST THE DEDUCTIBLE AMOUNT. IN NO EVENT WILL THE COMPANY BE LIABILE FOR DEFENSE COSTS OR

THE AMOUNT OF ANY JUDGEMENT OR SETTLEMENT IN EXCESS OF THE APPLICABLE LIMIT OF LIABILITY.

PLEASE READ THE ENTIRE EMPLOYMENT PRACTICES LIABILITY COVERAGE ENDORSEMENT CAREFULLY TO DETERMINE

RIGHTS, DUTIES AND WHAT IS AND IS NOT COVERED.

NAME OF APPLICANT: ______________________________________________________________________________

Address: ____________________________________________________________________________________________

GENERAL INFORMATION

[Note: Coverage is not available in Hawaii, or Louisiana.]

1. Number of full-time employees and recognized volunteers: _______ (Employees/recognized volunteers other than full-

time are to be counted as one-half an employee/recognized volunteer.)

2. Check the following boxes to identify your desired Limit of Insurance and Deductible:

Aggregate Limit of Liability

Vermont - Aggregate Limit of Liability

Defense/Indemnity

Per Claim Deductible

$25,000

N/A Arkansas, Montana, New Mexico

$25,000/$25,000

$2,500

$5,000

$50,000

N/A Arkansas, Montana, New Mexico

$37,500/$37,500

$2,500

$5,000

$75,000

N/A Arkansas, Montana, New Mexico

$50,000/$50,000

$2,500

$5,000

$10,000 VT only

$100,000

This is the minimum limit requirement

in Minnesota, New Hampshire, New

York, and North Dakota.

N/A Arkansas, Montana, New Mexico

$125,000/$125,000

$2,500

$5,000

$10,000

$25,000 VT only

$250,000

This is the maximum limit available for

Businessowners Coverage risks.

N/A Arkansas, Montana, New Mexico

$250,000/$250,000

$2,500

$5,000

$10,000

$25,000

$500,000

This is the minimum limit requirement

in Arkansas and New Mexico.

$500,000/$500,000

$2,500

$5,000

$10,000

$25,000

$1,000,000

This is the minimum limit requirement

in Montana.

Not applicable in VT

$2,500

$5,000

$10,000

$25,000

3. Desired effective date: ______________ Employment Practices Liability Retroactive Date: ______________

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4. Have there been any Employment Practices Liability claims, suits or complaints and/or is there any now pending

against the insured or any executive, officer or owner? Yes No

If yes, please provide details: ______________________________________________________________________

5. Does the insured and any executive, officer or owner have any knowledge or information of any act, error or omission

which might give rise to an Employment Practices Liability claim, suit or complaint? Yes No

If yes, please provide details: ______________________________________________________________________

Answer the following questions if you are requesting a Limit of Liability of $250,000 or greater. (Not applicable to

Businessowners Coverage risks.)

6. Has the insured been in continuous business with no bankruptcy filing for three (3) years or more? Yes No

7. Are all job applicants required to complete and sign an employment application? Yes No

8. Does the insured utilize an employment handbook, website or written employment materials (such as anti-harassment

or anti-discrimination policies) to advise employees of their rights to work free of harassment and discrimination in the

workplace? Yes No

9. In the past 12 months and the coming 12 months combined, has there been or does the insured expect any layoffs

or reductions in work force totaling more than 15% of the total employee count? Yes No

Fair Credit Report Act Notice: PERSONAL INFORMATION ABOUT YOU, INCLUDING INFORMATION FROM A CREDIT OR OTHER

INVESTIGATIVE REPORT, MAY BE COLLECTED FROM PERSONS OTHER THAN YOU IN CONNECTION WITH THIS APPLICATION FOR

INSURANCE AND SUBSEQUENT AMENDMENTS AND RENEWALS. SUCH INFORMATION AS WELL AS OTHER PERSONAL AND PRIVILEGED

INFORMATION COLLECTED BY US OR OUR AGENTS MAY IN CERTAIN CIRCUMSTANCES BE DISCLOSED TO THIRD PARTIES WITHOUT

YOUR AUTHORIZATION. CREDIT SCORING INFORMATION MAY BE USED TO HELP DETERMINE EITHER YOUR ELIGIBILITY FOR INSURANCE

OR THE PREMIUM YOU WILL BE CHARGED. WE MAY USE A THIRD PARTY IN CONNECTION WITH THE DEVELOPMENT OF YOUR SCORE.

YOU HAVE THE RIGHT TO REVIEW YOUR PERSONAL INFORMATION IN OUR FILES AND CAN REQUEST CORRECTION OF ANY

INACCURACIES. A MORE DETAILED DESCRIPTION OF YOUR RIGHTS AND OUR PRACTICES REGARDING SUCH INFORMATION IS

AVAILABLE UPON REQUEST. CONTACT YOUR AGENT OR BROKER FOR INSTRUCTIONS ON HOW TO SUBMIT A REQUEST TO US.

Fraud 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 THE PERSON TO CRIMINAL AND CIVIL PENALTIES. (NOT APPLICABLE IN AR, CO, DC, FL, HI, KY,

MA, MD, NJ, NM, NY, OH, OK, OR, PA, TN, VA, VT, WA OR WV)

Warranty Statement

The undersigned authorized officer of the Applicant declares that the statements set forth herein are true. The

undersigned authorized officer agrees that if the information supplied on this application changes between the

date of this Application and the effective date of the insurance, he/she (undersigned) will, in order for the

information to be accurate on the effective date of the insurance, immediately notify the insurer of such changes,

and the insurer may withdraw or modify any outstanding quotations and/or authorizations or agreements to bind

the insurance.

Signing of this application does not bind the applicant or the insurer to complete the insurance, but it is agreed

that this application shall be the basis of the contract should an Employment Practices Liability Coverage

Endorsement be issued, and the application is deemed to be attached to and shall become a part of the policy.

Applicant’s signature: __________________________________________________________Date:_________________

Title: __________________________________

Producer’s signature: __________________________________________________________Date:_________________

STATE FRAUD STATEMENTS

THIS NOTICE IS PART OF YOUR APPLICATION:

APPLICABLE IN ARKANSAS AND WEST VIRGINIA

ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR KNOWINGLY

PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND

CONFINEMENT IN PRISON.

APPLICABLE IN COLORADO

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IT IS UNLAWFUL TO KNOWINGLY PROVIDE FALSE, INCOMPLETE, OR MISLEADING FACTS OR INFORMATION TO AN INSURANCE COMPANY

FOR THE PURPOSE OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE COMPANY. PENALTIES MAY INCLUDE IMPRISONMENT, FINES,

DENIAL OF INSURANCE AND CIVIL DAMAGES. ANY INSURANCE COMPANY OR AGENT OF AN INSURANCE COMPANY WHO KNOWINGLY

PROVIDES FALSE, INCOMPLETE, OR MISLEADING FACTS OR INFORMATION TO A POLICYHOLDER OR CLAIMANT FOR THE PURPOSE OF

DEFRAUDING OR ATTEMPTING TO DEFRAUD THE POLICYHOLDER OR CLAIMING WITH REGARD TO A SETTLEMENT OR AWARD PAYABLE

FOR INSURANCE PROCEEDS SHALL BE REPORTED TO THE COLORADO DIVISION OF INSURANCE WITHIN THE DEPARTMENT OF

REGULATORY AGENCIES.

APPLICABLE IN THE DISTRICT OF COLUMBIA

WARNING: IT IS A CRIME TO PROVIDE FALSE OR MISLEADING INFORMATION TO AN INSURER FOR THE PURPOSE OF DEFRAUDING THE

INSURER OR ANY OTHER PERSON. PENALTIES INCLUDE IMPRISONMENT AND/OR FINES. IN ADDITION, AN INSURER MAY DENY

INSURANCE BENEFITS IF FALSE INFORMATION MATERIALLY RELATED TO A CLAIM WAS PROVIDED BY THE APPLICANT.

APPLICABLE IN FLORIDA

ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY INSURANCE COMPANY FILES A STATEMENT

OF CLAIM CONTAINING ANY FALSE, INCOMPLETE, OR MISLEADING INFORMATION IS GUILTY OF A FELONY OF THE THIRD DEGREE.

APPLICABLE IN HAWAII

FOR YOUR PROTECTION, HAWAII LAW REQUIRES YOU TO BE INFORMED THAT PRESENTING A FRAUDULENT CLAIM FOR PAYMENT OF A

LOSS OR BENEFIT IS A CRIME PUNISHABLE BY FINES OR IMPRISONMENT, OR BOTH.

APPLICABLE IN KENTUCKY

ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION

FOR INSURANCE CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS, FOR THE PURPOSE OF MISLEADING,

INFORMATION CONCERNING ANY FACT MATERIAL THERETO COMMITS A FRAUDULENT ACT, WHICH IS A CRIME.

APPLICABLE IN MAINE

IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE OR MISLEADING INFORMATION TO AN INSURANCE COMPANY FOR THE

PURPOSE OF DEFRAUDING THE COMPANY. PENALTIES MAY INCLUDE IMPRISONMENT, FINES, OR DENIAL OF INSURANCE BENEFITS.

APPLICABLE IN MARYLAND

ANY PERSON WHO KNOWINGLY AND WILLFULLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR

WHO KNOWINGLY AND WILLFULLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND

MAY BE SUBJECT TO FINES AND CONFINEMENT IN PRISON.

APPLICABLE IN NEW JERSEY

ANY PERSON WHO INCLUDES ANY FALSE OR MISLEADING INFORMATION ON AN APPLICATION FOR AN INSURANCE POLICY IS SUBJECT

TO CRIMINAL AND CIVIL PENALTIES.

APPLICABLE IN NEW MEXICO

ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR KNOWINGLY

PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GULTY OF A CRIME AND MAY BE SUBJECT TO CIVIL FINES AND

CRIMINAL PENALTIES.

APPLICABLE IN NEW YORK

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 SHALL ALSO BE SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE SATED VALUE OF THE

CLAIM FOR EACH SUCH VIOLATION.

APPLICABLE IN OHIO

ANY PERSON WHO, WITH INTENT TO DEFRAUD OR KNOWING THAT HE/SHE IS FACILITATING A FRAUD AGAINST AN INSURER, SUBMITS

AN APPLICATION OR FILES A CLAIM CONTAINING A FALSE OR DECEPTIVE STATEMENT IS GUILTY OF INSURANCE FRAUD.

APPLICABLE IN OKLAHOMA

WARNING: ANY PERSON WHO KNOWINGLY, AND WITH INTENT TO INJURE, DEFRAUD OR DECEIVE ANY INSURER, MAKES ANY CLAIM FOR

THE PROCEEDS OF AN INSURANCE POLICY CONTAINING ANY FALSE, INCOMPLETE OR MISLEADING INFORMATION IS GUILTY OF A

FELONY.

APPLICABLE IN OREGON

ANY PERSON WHO, WITH INTENET TO DEFRAUD OR KNOWING THAT HE OR SHE IS FACILITATING A FRAUD AGAINST AN INSURER,

SUBMITS AN APPLICATION OR FILES A CLAIM CONTAINING A FALSE OR DECEPTIVE STATEMENT MAY BE GUILTY OF INSURANCE FRAUD.

APPLICABLE IN PENNSYLVANIA

ANY PERSON WHO KNOWINGLY AND WITH INTENET 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.

APPLICABLE IN TENNESSEEE, VIRGINIA AND WASHINGTON

IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE OR MISLEADING INFORMATION TO AN INSURANCE COMPANY FOR THE

PURPOSE OF DEFRAUDING THE COMPANY. PENALTIES INCLUDE IMPRISONMENT, FINES AND DENIAL OF INSURANCE BENEFITS.

APPLICABLE IN VERMONT

ANY PERSON WHO KNOWINGLY PRESENTS A FALSE STATEMENT IN AN APPLICATION FOR INSURANCE MAY BE GUILTY OF A CRIMINAL

OFFENSE AND SUBJECT TO PENALTIES UNDER STATE LAW.