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Application Information

Business Name (including DBA names)*

Primary Contact*

First Name* Last Name*

Mailing Address*

Street Address* City* State* ZIP Code*

Website

Email Address*

Date Established*

MM slash DD slash YYYY Date Established*

Phone Number*

FEIN Number*

Form of Business*

Individual

Professional Corporation

Partnership

Professional Association

LLC or LLP

Other

Branch Office(s)/Subsidary(ies)

Description of Operations*

Coverage Desired

Yes

Business Owners

Is the location address the same as the mailing address listed above*

Yes

Location Address*

Street Address* City* State* ZIP Code*

Construction Type*

Year Built*

Square Footage of Building*

Percentage of Building Occupied*

Prior Insurance Carrier

Effective Dates

Premium

Total Number of Business Owner’s claims in the past 3 years

Business owner’s loss history (please complete below)

Date

MM slash DD slash YYYY Date

Type/Description

Amount Paid

Amount Reserved

Open/Closed

Section Break

Contents Coverage*

Deductible

Computer Hardware

Computer Software

Personnel Consultant Professional Liability

Past Fiscal Year (12 Month Actual)

Current Fiscal Year (Estimate if necessary)

Total Gross Annual Revenue*

Does the Applicant provide any professional services other than permanent placement?*

Yes

Please describe the services provided*

Does the Applicant utilize the services of independent contractors or sub-Consultants?*

Yes

Does the Applicant secure a written contract or agreement for every project?*

Yes

Does the contract stipulate who is responsible for background check of candidates for placement?*

Yes

Does the Applicant provide background checks on any candidates for Placement?*

Yes

Does the Applicant sub-contract background checks to another party?*

Yes

Does the Applicant require a hold harmless or indemnification clause in the Applicant’s favor?*

Yes

Is the Applicant involved in any hiring or firing decisions?*

Yes

What percentage of the Applicant’s gross annual revenue is derived from placements with salaries greater than $100,000?*

Please indicate the percentage of types of professionals placed in the past 12 months

Chief Executive Officers

Percentage

Architects/Engineers

Percentage

Financial Advisors

Percentage

Chief Financial Officers

Percentage

Bookkeeper/Accountant/Payroll

Percentage

Insurance

Percentage

Other Management and Executives

Percentage

Lawyers

Percentage

Physician/Surgeon

Percentage

Office Based Professionals (non-legal,non-financial)

Percentage

Real Estate

Percentage

Information Technology

Percentage

Other (specify):

Percentage

Other (specify):

Percentage

Other (specify):

Percentage

Total number of Professional Liability claims in the past 5 years?*

Professional Liability Loss History (please complete below):

Date, Type/Description, Amount Paid, Amount Reserved, Open/Closed

NOTICE: The Employment Practices Liability coverage is provided on a claims-made basis and covers only those claims first made during the policy period and reported in writing to the Underwriter pursuant to the terms herein subsequent renewal of this policy or any extended reporting period are covered, subject to policy provisions. The Employment Practices Liability policy provides a limit of liability available to pay judgments or settlements that shall be reduced by amounts incurred as defense costs. Further note that defense costs paid shall be applied against the retention amount.

Please provide a breakdown of the Applicant’s In House Corporate Employees

Total Number of Full Time Corporate Employees:*

Prior Year Actual/Next Fiscal Year Projection

Total Number of Part Time Corporate Employees:*

Prior Year Actual/Next Fiscal Year Projection

Total Number of Independent Contractors:*

Prior Year Actual/Next Fiscal Year Projection

How many of the Applicant’s Corporate Employees have been terminated or demoted in the past twelve Months?*

Voluntary, Involuntary, Laid Off

Is any reduction in corporate employees anticipated within the next year?*

Yes

Does the Applicant:

Have a standard employment application for all job applicants?*

Yes

Have an employment handbook?*

Yes

Document the receipt of the employee handbook by employee?*

Yes

Have an At Will provision in the employment application?*

Yes

Have a written policy with respect to sexual harassment?*

Yes

Have a written policy with respect to discrimination?*

Yes

Have a human resource department?*

Yes

Has the Applicant given written notice under the provisions of any prior policies providing similar insurance or claims, or of specific facts or circumstances which might give rise to a claim being made against any person or entity applying for this insurance?*

Yes

Please provide a description of the type of allegations, court or agency involved and any determination, judgement, defense cost or settlement for each.*

No person applying for Employment Practices Liability coverage is aware of any facts or circumstances which he or she has reason to presume might give rise to a future claim that would fall within the scope of any proposed coverages for which the Applicant has applied except:*

None

As Noted Below

Crime

Does the Applicant conduct a prior employment check on all new hires?*

Yes

Does the Applicant conduct a criminal background check?*

Yes

Are the owners involved in the daily operations of the company?*

Yes

Are two signatures required on checks?*

Yes

Over what amount?*

Who has the authority to sign checks?*

Do employees who reconcile bank statements also:

Sign checks?*

Yes

Make withdrawals?*

Yes

Make deposits?*

Yes

Have access to blank checks?*

Yes

Have access to computer systems that print checks?*

Yes

Have access to facsimile, signature plate or check signing machines?*

Yes

Disclaimer and Signature

The Undersigned states that he/she is an authorized representative of the Applicant and declares to the best of his/her knowledge and belief and after reasonable inquiry, that the statements set forth in this Application (and any attachments submitted with this Application) are true and complete and may be relied upon by Company* in quoting and issuing the policy. If any of the information in this Application changes prior to the effective date of the policy, the Applicant will notify the Company of such changes, and the Company may modify or withdraw the quote or Binder. The signing of this Application does not bind the Company to offer or the Applicant to purchase the policy.

*Company refers collectively to Philadelphia Indemnity Insurance Company and Tokio Marine Specialty Insurance Company.

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 insurance act, which is a crime and subjects that person to criminal and civil penalties (in Oregon, the aforementioned actions may constitute a fraudulent insurance act which may be a crime and may subject the person to penalties), (In New York, the civil penalty is not to exceed five thousand dollars ($5,000) and the stated value of the claim for each such violation). *(Not applicable in AL, AR, AZ, CO, DC, FL, KS, LA, ME, MD, MN, NM, OK, PA, RI, TN, VA, VT, WA, and WV)

Applicable in AL, AR, AZ, DC, LA, MD, NM, RI and WV: Any person who knowingly (or willfully in MD) presents a false or fraudulent claim for payment of a loss benefit or who knowingly (or willfully in MD) presents false information in an application for insurance is guilty of a crime and may be subject to fines or confinement in prison.

Applicable in Colorado: 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 claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.

Applicable in Florida and Oklahoma: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony (in FL, a person is guilty of a felony of the third degree).

Applicable in Kansas: An act committed by any person who, knowingly and with intent to defraud, presents, causes to be presented or prepares with knowledge or belief that it will be presented to or by an insurer, purported insurer, broker or any agent thereof, any written, electronic, electronic impulse, facsimile, magnetic, oral or telephonic communication or statement as part of, or in support of, an application for the issuance of, or the rating of an insurance policy for personal or commercial insurance, or a claim for payment or other benefit pursuant to an insurance policy for commercial or personal insurance which such person knows to contain materially false information concerning any fact material thereto; or conceals for the purpose of misleading, information concerning any fact material thereto.

Applicable in Kentucky: Any person who knowingly and with intent to defraud any insurance company or other persons, files an application for insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any material thereto commits a fraudulent insurance act, which is a crime.

Applicable in Maine, Tennessee, 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 may include imprisonment, fines, or a denial of insurance benefits.

Applicable in Pennsylvania:,/strong> 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 such person to criminal and civil 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 be subject to a civil penalty not to exceed five thousand dollars and the state value of the claim for each such violation.

Virtual Signature*

Date*

MM slash DD slash YYYY Date*

Title*

*COVERAGE CANNOT BE ISSUED UNLESS THE QUESTIONNAIRE IS PROPERLY SIGNED AND DATED.

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