Your company name:

Mailing address:

Are you a sole proprietor:      Corporation:      Partnership:    Other:

Years in business:

Contact person:

Phone number:

Fax number

Company website address:

Contact e-mail address:

Type of business:

Description of business/operations:

Actual property address if different from mailing address:

Number of non-union employees: full time, part time, seasonal:

Number of union employees: Full time, part time, seasonal:

Any losses last 5 years: Yes: No: .

Please list on all charges, demand letters, EEOC charges or complaints from current or former employees that have been made against you for the past 5 years.  Please include the following information:

Are you aware of any facts, incidents or circumstances which may result in a claim or claims being made against you?  If yes, please state yes and describe details.   If no, please state "no" 

How many employees have been terminated over the past 3 years

Do you anticipate any layoffs, staff reductions or plant closings during the next 12 months?

Do you intend to make any acquisitions during the next 12 months?

Do you have a Human Resource or Personnel Department? 

Do you train your managers regarding employment practices issues? 

Do you have an employee handbook that is distributed to all employees?

Does your handbook inform employees that they are "at will" employees?

Limit of liability requested: $

Any Special Instructions: 

How did you hear about ABC Insurance?

For your records, please print this page. When the application is complete, click below to submit to ABC Insurance.