Employment Practices Insurance

General Information
Name of Parent Company*
Address*
Street Address City State ZIP Code
Phone
Email
Standard Industrial Classification Code (SIC):*
Nature of Operations:*
Has the Company been in business longer then three (3) years?*
- Yes
- No
Is the Company public-held or a public reporting company under the Securities Exchange Act of 1934?*
- Yes
- No
Does the Parent Company own more than three (3) subsidiaries? If yes, please provide details in the box below.*
- Yes
- No
Details.*
Has the Company in the past 18 months been involved with any actual, negotiated or attempted merger, acquisition or divestment? If yes, please use the box below to provide details.*
- Yes
- No
Details.*
Does the Company contemplate transacting any mergers or acquisitions in the next 12 months where such merger or acquisition would involve more the 50% of the total assets of the Company? If yes, please use the box below to provide more details.*
- Yes
- No
Details.*

Prior Activites Information
Within the last three (3) years, has any person or entity proposed for this insurance been the subject of or involved in any litigation, administrative proceeding. demand letter or formal or informal government investigation or inquiry including any investigation by the Department of Labor or the Equal Emplayment Opportunity Commission. If yes, please use the box below to provide details.*
- Yes
- No
Details*
Within the last three (3) years, has any person or entity proposed for this insurance has any crime losses. If yes, please use the box below to provide details.*
- Yes
- No
Details*

General Information