Employment Practices Liability

Protecting Employers......


Company Name:
     Contact Person: 
   State:     Zipcode: 
Phone Number:
E-Mail Address:
What does your company do?
     Years in Business: 


Current number of employees (full and part-time) for all locations & subsidiaries:  Full Time:  / Part Time: 
Has the company laid-off (excluding seasonal layoffs) or terminated more than 30% of its workforce in the past twelve months?  If Yes, please complete the "Reduction in Force Section". Yes /  No
Does the company anticipate any layoffs (excluding seasonal layoffs), downsizing or office or plant closings in the next twelve months?  If Yes, please complete the "Reduction in Force Section". Yes /  No
Does the company currently have and regularly distribute the following written policies?
A. Employment at-will statement:
B. Anti-Discrimination
C. Harassment
Yes /  No
Yes /  No
Yes /  No
Past History
Within the past 3 years, has the company had any lawsuits, threatened claim, or charges filed with the EEOC or state/local administrative agency involving a Wrongful Employment Act, or Third-Party Wrongful Act? If Yes, please complete the Claim(s) section. Yes /  No
Does any director, officer, owner, member, or partner of the company have knowledge of any fact, circumstance, or situation which may result in a claim, such as would fall under the proposed insurance? Yes /  No

Prior Coverage   Does the company currently carry employment practices liability insurance?  Yes /  No

Policy Period Insurance Company Limit of Liability Deductible/Retention Limit Effective Date (month/day/year)
of First Year of
EPLI Coverage
Reduction in Force Section (only if there was or will be a reduction in your employees)

What is the reason for the reduction in force (e.g. layoff, staff reduction, or office or plant closing) or the high termination rate?

How many employees have been terminated, or have been or will be affected by the reduction in force? 

On what date, was, or is; the reduction in force effective? 

What criteria (e.g. expertise, seniority, performance, etc) will be, or was, used to determine which employees will be affected by the reduction in force?

Will, or did, the company consult with legal counsel prior to the reduction in force?   Yes /  No

Will, or did, the company require the affected employees to sign a release for their severance package?    Yes /  No

Claim(s) Section  (only if there was a claim)

Name of Claimant or Potential Claimant and Position/Title with the company:

Date alleged claim or circumstance occurred? 

What is the status of the claim or circumstances?     Closed /  Open /  Potential

Amount of Defense Costs paid (if any): $       Settlement Amount (if any): $ 

Expenses paid by the company, including any expenses paid by any insurer (if any): $ 


M c G R A T H   I N S U R A N C E   G R O U P

4170 William Penn Highway    Murrysville, PA.   15668-1890
(724) 327-8474       Fax: (724) 327-7911
Toll Free: 1-800-977-2999      Fax: 1-888-800-0034
www.McGrathInsuranceGroup.com        McGrathInsurance@verizon.net