Employment Practice Liability Quote

Name of Organization:

FEIN #:

Physical Address:

Mailing Address:If Different

Contact Person:

Emaila valid email

Phone:

Fax:

What are the opterations of the organization?more details

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Number of Employees:

# of Full time

# of Temporary Seasonal:

# of Volunteers:

# of Part time

# of Independent contractors

Has there been an Employment Practice Liability Insurance claim in the past 5 years?pick one!

YesNo

If Yes, please explain:more details

0 /

Additional Comments:more details

0 /