EPLI Non-Binding Premium Indication Form
Licensed to sell insurance in the states of Illinois, Indiana, Wisconsin, and Colorado. Any offer of insurance coverage resulting from the submission of this Non-Binding Premium Indication form shall be an estimate of premium cost, forms, terms and conditions. To secure a bindable quotation, it will be necessary to complete an application and submit all required information and supporting documents. No coverage is provided by the submission of this form.
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indicates required fields
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Full Company Name:
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Address:
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Date Established:
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Website Address:
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Describe the Nature of Company's Operations:
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Total Full Time Employees This Year:
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Total Full Time Employees Last Year:
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Total Part Time Employees This Year:
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Total Part Time Employees Last Year:
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Number of Employees Located in California:
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Number of Employees Located in Florida:
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Number of Employees Located in New Jersey:
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Number of Employees Located in New York:
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Number of Employees Located in Texas:
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Do You Currently Have EPLI Coverage:
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Yes
No
If Yes, With What Company?:
If Yes, Current Limit of Liability:
If Yes, Current Deductible or Retention:
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Has Your Company Had Any Employment Related Claims or Suits in the last 5 Years?:
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Yes
No
If Yes, Please Provide Details:
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Your Phone Number:
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Your Email Address:
After completing this form, click on the SUBMIT button.
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