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ACORD 188 (2003/02) 1 of 16
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Universal wording updates to improve clarity and intent were made to all FIG text for this form on 05/08/2009. |
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Section Name |
Field Name |
Field and/or Section Description |
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TITLE ACORD 188 (2003/02) |
Employment Related Practices Liability Section |
The title of the form. ACORD 188, Employment Related Practices Liability Section, is used to apply for Employment Related Practices Liability coverage. This form is intended to be used with ACORD 125, Commercial Insurance Application. |
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IDENTIFICATION |
Date |
Enter date: The month/day/year on which the form is completed. (MM/DD/YYYY) |
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IDENTIFICATION |
Producer |
Enter text: The full name of the producer/agency. |
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IDENTIFICATION |
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Enter text: The mailing address line one of the producer/agency. |
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IDENTIFICATION |
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Enter text: The mailing address line two of the producer/agency. |
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IDENTIFICATION |
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Enter text: The mailing address city name of the producer/agency. |
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IDENTIFICATION |
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Enter code: The mailing address state or province code of the producer/agency. |
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IDENTIFICATION |
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Enter code: The mailing address postal code of the producer/agency. |
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IDENTIFICATION |
Phone No. |
Enter number: The producer's contact person's phone number. If applicable, include the area code and extension. |
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IDENTIFICATION |
Fax No. |
Enter number: The fax number of the producer/agency. |
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IDENTIFICATION |
Code |
Enter code: The identification code assigned to the producer (e.g. agency or brokerage firm) by the insurer. |
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IDENTIFICATION |
Subcode |
Enter code: The identification code assigned by the insurer to the sub-producer (e.g. person) within a producer's office (e.g. agency or brokerage). |
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IDENTIFICATION |
Agency Customer ID |
Enter identifier: The customer's identification number assigned by the producer (e.g. agency or brokerage). |
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IDENTIFICATION |
Applicant (First Named Insured) |
Enter text: The named insured(s) as it/they will appear on the policy declarations page. |
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IDENTIFICATION |
Proposed Effective Date |
Enter date: The effective date of the policy. The date that the terms and conditions of the policy commence. |
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IDENTIFICATION |
Proposed Expiration Date |
Enter date: The date on which the terms and conditions of the policy will expire. |
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IDENTIFICATION |
Proposed Retroactive Date |
Enter date: The retroactive date you are requesting for the policy being applied for. This is the proposed earliest date for which an occurrence could "trigger" coverage under a Claims Made policy. |
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IDENTIFICATION |
For Company Use Only |
Enter text: This area is to be completed by the insurer. |
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COVERAGE |
Limit of Liability ($) |
Enter amount: The limit for liability coverage. |
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COVERAGE |
Co-Payment AMT ($) |
Enter amount: The co-payment amount. |
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COVERAGE |
Other |
Enter text: The description of any other pertinent information required by the insurer. |
ACORD 188 (2003/02) 2 of 16
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Section Name |
Field Name |
Field and/or Section Description |
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INSURANCE INFORMATION |
Person responsible for handling ERPL claims: |
Enter text: The full name of the person the insurer is to contact regarding any potential claims inquiries. As used here, answer all questions. Note that current and prior coverage information relates only to the coverage request under this application. |
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INSURANCE INFORMATION |
Telephone |
Enter number: The telephone number of the person the insurer is to contact regarding any potential claims inquiries. |
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INSURANCE INFORMATION |
E-Mail |
Enter text: The e-mail address (if applicable) of the person the insurer is to contact regarding any potential claims inquiries. |
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INSURANCE INFORMATION |
Fax |
Enter number: The fax number of the person the insurer is to contact regarding any potential claims inquiries. |
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INSURANCE INFORMATION |
Do you currently carry ERPL insurance? Yes |
Check the box (if applicable): Indicates a "Yes" response to the question, "Do you currently carry ERPL Insurance?". |
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INSURANCE INFORMATION |
No |
Check the box (if applicable): Indicates a "No" response to the question, "Do you currently carry ERPL Insurance?". |
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INSURANCE INFORMATION |
If Yes, Insurer: |
Enter text: The name of the previous insurer. |
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INSURANCE INFORMATION |
Policy Period Eff Date One |
Enter date: The effective date of the prior policy. As used here, this refers to your ERPL Insurance. |
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INSURANCE INFORMATION |
Policy Period Exp Date One |
Enter date: The expiration date of the previous coverage. As used here, this refers to your ERPL Insurance. |
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INSURANCE INFORMATION |
Premium One |
Enter amount: The annual modified premium charged (not including taxes or service charges) for the specified line of business. As used here, this refers to your ERPL Insurance. |
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INSURANCE INFORMATION |
Limit One |
Enter limit: The limit amount of the prior coverage. As used here, this refers to your ERPL Insurance. |
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INSURANCE INFORMATION |
Deductible One |
Enter deductible: The deductible amount of the prior coverage. As used here, this refers to your ERPL Insurance. |
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INSURANCE INFORMATION |
%Co-Pay1 One |
Enter amount: The co-payment amount. As used here, this refers to your ERPL Insurance. |
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INSURANCE INFORMATION |
Retro Date1 One |
Enter date: The retroactive date for the policy being described. As used here, this refers to your ERPL Insurance. |
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INSURANCE INFORMATION |
Insurer One |
Enter text: The name of the previous insurer. As used here, this refers to your ERPL Insurance. |
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INSURANCE INFORMATION |
Policy Period Eff Date Two |
Enter date: The effective date of the prior policy. As used here, this refers to your ERPL Insurance. |
ACORD 188 (2003/02) 3 of 16
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Section Name |
Field Name |
Field and/or Section Description |
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INSURANCE INFORMATION |
Policy Period Exp Date Two |
Enter date: The expiration date of the previous coverage. As used here, this refers to your ERPL Insurance. |
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INSURANCE INFORMATION |
Premium Two |
Enter amount: The annual modified premium charged (not including taxes or service charges) for the specified line of business. As used here, this refers to your ERPL Insurance. |
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INSURANCE INFORMATION |
Limit Two |
Enter limit: The limit amount of the prior coverage. As used here, this refers to your ERPL Insurance. |
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INSURANCE INFORMATION |
Deductible Two |
Enter deductible: The deductible amount of the prior coverage. As used here, this refers to your ERPL Insurance. |
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INSURANCE INFORMATION |
%Co-Pay1 Two |
Enter amount: The co-payment amount. As used here, this refers to your ERPL Insurance. |
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INSURANCE INFORMATION |
Retro Date1 Two |
Enter date: The retroactive date for the policy being described. As used here, this refers to your ERPL Insurance. |
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INSURANCE INFORMATION |
Insurer Two |
Enter text: The name of the previous insurer. As used here, this refers to your ERPL Insurance. |
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INSURANCE INFORMATION |
Policy Period Eff Date Three |
Enter date: The effective date of the prior policy. As used here, this refers to your ERPL Insurance. |
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INSURANCE INFORMATION |
Policy Period Exp Date Three |
Enter date: The expiration date of the previous coverage. As used here, this refers to your ERPL Insurance. |
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INSURANCE INFORMATION |
Premium Three |
Enter amount: The annual modified premium charged (not including taxes or service charges) for the specified line of business. As used here, this refers to your ERPL Insurance. |
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INSURANCE INFORMATION |
Limit Three |
Enter limit: The limit amount of the prior coverage. As used here, this refers to your ERPL Insurance. |
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INSURANCE INFORMATION |
Deductible Three |
Enter deductible: The deductible amount of the prior coverage. As used here, this refers to your ERPL Insurance. |
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INSURANCE INFORMATION |
%Co-Pay1 Three |
Enter amount: The co-payment amount. As used here, this refers to your ERPL Insurance. |
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INSURANCE INFORMATION |
Retro Date1 Three |
Enter date: The retroactive date for the policy being described. As used here, this refers to your ERPL Insurance. |
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INSURANCE INFORMATION |
Insurer Three |
Enter text: The name of the previous insurer. As used here, this refers to your ERPL Insurance. |
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INSURANCE INFORMATION |
Policy Period Eff Date Four |
Enter date: The effective date of the prior policy. As used here, this refers to your ERPL Insurance. |
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INSURANCE INFORMATION |
Policy Period Exp Date Four |
Enter date: The expiration date of the previous coverage. As used here, this refers to your ERPL Insurance. |
ACORD 188 (2003/02) 4 of 16
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Section Name |
Field Name |
Field and/or Section Description |
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INSURANCE INFORMATION |
Premium Four |
Enter amount: The annual modified premium charged (not including taxes or service charges) for the specified line of business. As used here, this refers to your ERPL Insurance. |
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INSURANCE INFORMATION |
Limit Four |
Enter limit: The limit amount of the prior coverage. As used here, this refers to your ERPL Insurance. |
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INSURANCE INFORMATION |
Deductible Four |
Enter deductible: The deductible amount of the prior coverage. As used here, this refers to your ERPL Insurance. |
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INSURANCE INFORMATION |
%Co-Pay1 Four |
Enter amount: The co-payment amount. As used here, this refers to your ERPL Insurance. |
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INSURANCE INFORMATION |
Retro Date1 Four |
Enter date: The retroactive date for the policy being described. As used here, this refers to your ERPL Insurance. |
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INSURANCE INFORMATION |
Insurer Four |
Enter text: The name of the previous insurer. As used here, this refers to your ERPL Insurance. |
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INSURANCE INFORMATION |
Policy Period Eff Date Five |
Enter date: The effective date of the prior policy. |
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INSURANCE INFORMATION |
Policy Period Exp Date Five |
Enter date: The expiration date of the previous coverage. |
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INSURANCE INFORMATION |
Premium Five |
Enter amount: The annual modified premium charged (not including taxes or service charges) for the specified line of business. |
|
INSURANCE INFORMATION |
Limit Five |
Enter limit: The limit amount of the prior coverage. |
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INSURANCE INFORMATION |
Deductible Five |
Enter deductible: The deductible amount of the prior coverage. |
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INSURANCE INFORMATION |
% Co-Pay Five |
Enter amount: The co-payment amount. |
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INSURANCE INFORMATION |
Retro Date Five |
Enter date: The retroactive date for the policy being described. |
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INSURANCE INFORMATION |
Insurer Five |
Enter text: The name of the previous insurer. |
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INSURANCE INFORMATION |
Policy Period Eff Date Six |
Enter date: The effective date of the prior policy. |
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INSURANCE INFORMATION |
Policy Period Exp Date Six |
Enter date: The expiration date of the previous coverage. |
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INSURANCE INFORMATION |
Premium Six |
Enter amount: The annual modified premium charged (not including taxes or service charges) for the specified line of business. |
ACORD 188 (2003/02) 5 of 16
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Section Name |
Field Name |
Field and/or Section Description |
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INSURANCE INFORMATION |
Limit Six |
Enter limit: The limit amount of the prior coverage. |
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INSURANCE INFORMATION |
Deductible Six |
Enter deductible: The deductible amount of the prior coverage. |
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INSURANCE INFORMATION |
% Co-Pay Six |
Enter amount: The co-payment amount. |
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INSURANCE INFORMATION |
Retro Date Six |
Enter date: The retroactive date for the policy being described. |
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INSURANCE INFORMATION |
Insurer Six |
Enter text: The name of the previous insurer. |
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INSURANCE INFORMATION |
Policy Period Eff Date Seven |
Enter date: The effective date of the prior policy. |
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INSURANCE INFORMATION |
Policy Period Exp Date Seven |
Enter date: The expiration date of the previous coverage. |
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INSURANCE INFORMATION |
Premium Seven |
Enter amount: The annual modified premium charged (not including taxes or service charges) for the specified line of business. |
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INSURANCE INFORMATION |
Limit Seven |
Enter limit: The limit amount of the prior coverage. |
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INSURANCE INFORMATION |
Deductible Seven |
Enter deductible: The deductible amount of the prior coverage. |
|
INSURANCE INFORMATION |
% Co-Pay Seven |
Enter amount: The co-payment amount. |
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INSURANCE INFORMATION |
Retro Date Seven |
Enter date: The retroactive date for the policy being described. |
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INSURANCE INFORMATION |
Insurer Seven |
Enter text: The name of the previous insurer. |
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EMPLOYEE INFORMATION |
State One |
Enter code: The state or province code where the employees are located. |
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EMPLOYEE INFORMATION |
Country One |
Enter code: The country code where the employees are located. |
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EMPLOYEE INFORMATION |
Number of Locations One |
Enter number: The number of locations in the state, province, or country. |
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EMPLOYEE INFORMATION |
Total number of employees One |
Enter number: The total number of employees in the state, province or country. |
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EMPLOYEE INFORMATION |
State Two |
Enter code: The state or province code where the employees are located. |
ACORD 188 (2003/02) 6 of 16
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Section Name |
Field Name |
Field and/or Section Description |
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EMPLOYEE INFORMATION |
Country Two |
Enter code: The country code where the employees are located. |
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EMPLOYEE INFORMATION |
Number of Locations Two |
Enter number: The number of locations in the state, province, or country. |
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EMPLOYEE INFORMATION |
Total number of employees Two |
Enter number: The total number of employees in the state, province or country. |
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EMPLOYEE INFORMATION |
State Three |
Enter code: The state or province code where the employees are located. |
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EMPLOYEE INFORMATION |
Country Three |
Enter code: The country code where the employees are located. |
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EMPLOYEE INFORMATION |
Number of Locations Three |
Enter number: The number of locations in the state, province, or country. |
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EMPLOYEE INFORMATION |
Total number of employees Three |
Enter number: The total number of employees in the state, province or country. |
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EMPLOYEE INFORMATION |
State Four |
Enter code: The state or province code where the employees are located. |
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EMPLOYEE INFORMATION |
Country Four |
Enter code: The country code where the employees are located. |
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EMPLOYEE INFORMATION |
Number of Locations Four |
Enter number: The number of locations in the state, province, or country. |
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EMPLOYEE INFORMATION |
Total number of employees Four |
Enter number: The total number of employees in the state, province or country. |
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EMPLOYEE INFORMATION |
State Five |
Enter code: The state or province code where the employees are located. |
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EMPLOYEE INFORMATION |
Country Five |
Enter code: The country code where the employees are located. |
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EMPLOYEE INFORMATION |
Number of Locations Five |
Enter number: The number of locations in the state, province, or country. |
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EMPLOYEE INFORMATION |
Total number of employees Five |
Enter number: The total number of employees in the state, province or country. |
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EMPLOYEE INFORMATION |
Subsidiaries Name One |
Enter text: The name of the subsidiary of the company. This may also contain owned foundations or charitable trusts. |
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EMPLOYEE INFORMATION |
State One |
Enter code: The state or province code where the employees are located. |
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EMPLOYEE INFORMATION |
Country One |
Enter code: The country code where the employees are located. |
ACORD 188 (2003/02) 7 of 16
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Section Name |
Field Name |
Field and/or Section Description |
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EMPLOYEE INFORMATION |
Total number of employees One |
Enter number: The total number of employees in the state, province or country. |
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EMPLOYEE INFORMATION |
Subsidiaries Name Two |
Enter text: The name of the subsidiary of the company. This may also contain owned foundations or charitable trusts. |
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EMPLOYEE INFORMATION |
State Two |
Enter code: The state or province code where the employees are located. |
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EMPLOYEE INFORMATION |
Country Two |
Enter code: The country code where the employees are located. |
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EMPLOYEE INFORMATION |
Total number of employees Two |
Enter number: The total number of employees in the state, province or country. |
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EMPLOYEE INFORMATION |
Subsidiaries Name Three |
Enter text: The name of the subsidiary of the company. This may also contain owned foundations or charitable trusts. |
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EMPLOYEE INFORMATION |
State Three |
Enter code: The state or province code where the employees are located. |
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EMPLOYEE INFORMATION |
Country Three |
Enter code: The country code where the employees are located. |
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EMPLOYEE INFORMATION |
Total number of employees Three |
Enter number: The total number of employees in the state, province or country. |
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EMPLOYEE INFORMATION |
Subsidiaries Name Four |
Enter text: The name of the subsidiary of the company. This may also contain owned foundations or charitable trusts. |
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EMPLOYEE INFORMATION |
State Four |
Enter code: The state or province code where the employees are located. |
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EMPLOYEE INFORMATION |
Country Four |
Enter code: The country code where the employees are located. |
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EMPLOYEE INFORMATION |
Total number of employees Four |
Enter number: The total number of employees in the state, province or country. |
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EMPLOYEE INFORMATION |
Subsidiaries Name Five |
Enter text: The name of the subsidiary of the company. This may also contain owned foundations or charitable trusts. |
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EMPLOYEE INFORMATION |
State Five |
Enter code: The state or province code where the employees are located. |
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EMPLOYEE INFORMATION |
Country Five |
Enter code: The country code where the employees are located. |
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EMPLOYEE INFORMATION |
Total number of employees Five |
Enter number: The total number of employees in the state, province or country. |
ACORD 188 (2003/02) 8 of 16
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Section Name |
Field Name |
Field and/or Section Description |
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Enter text: The general remarks associated with the employment related practices liability |
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line of business. List any additional, pertinent information that the underwriter should |
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REMARKS |
Remarks |
know about the overall exposures of this risk. |
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EMPLOYEE INFORMATION |
Total Number of U.S. Employees |
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(continued) |
Full Time |
Enter number: The number of full time employees in the USA. |
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EMPLOYEE INFORMATION |
Total Number of U.S. Employees |
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(continued) |
Part Time: |
Enter number: The number of part time employees in the USA. |
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EMPLOYEE INFORMATION |
Total Number of U.S. Employees |
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(continued) |
Temporary: |
Enter number: The number of temporary employees in the USA. |
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EMPLOYEE INFORMATION |
Total Number of U.S. Employees |
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(continued) |
Seasonal: |
Enter number: The number of seasonal employees in the USA. |
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EMPLOYEE INFORMATION |
Total number of fair labor |
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(continued) |
standards act exempt employees |
Enter number: The number of fair labor standards act exempt employees. |
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Total number of fair labor |
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EMPLOYEE INFORMATION |
standards act non-exempt |
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(continued) |
employees |
Enter number: The number of fair labor standards act non-exempt employees. |
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EMPLOYEE INFORMATION |
Total number of unionized |
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(continued) |
employees in the USA |
Enter number: The number of unionized employees in the USA. |
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EMPLOYEE INFORMATION |
Total Number of Non- U.S. |
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(continued) |
Employees Full Time: |
Enter number: The number of full time employees outside the USA. |
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EMPLOYEE INFORMATION |
Total Number of Non- U.S. |
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(continued) |
Employees Part Time: |
Enter number: The number of part time employees outside the USA. |
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EMPLOYEE INFORMATION |
Total Number of Non- U.S. |
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(continued) |
Employees Temporary: |
Enter number: The number of temporary employees outside the USA. |
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EMPLOYEE INFORMATION |
Total Number of Non- U.S. |
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(continued) |
Employees Seasonal: |
Enter number: The number of seasonal employees outside the USA. |
ACORD 188 (2003/02) 9 of 16
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Section Name |
Field Name |
Field and/or Section Description |
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EMPLOYEE INFORMATION (continued) |
Total Number of All Employees Past 3 Years Year One |
Enter year: The year associated with the employee information. |
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EMPLOYEE INFORMATION (continued) |
Total Number of All Employees Past 3 Years Total # One |
Enter number: The total number of employees in the state, province or country. |
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EMPLOYEE INFORMATION (continued) |
Total Number of All Employees Past 3 Years Year Two |
Enter year: The year associated with the employee information. |
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EMPLOYEE INFORMATION (continued) |
Total Number of All Employees Past 3 Years Total # Two |
Enter number: The total number of employees in the state, province or country. |
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EMPLOYEE INFORMATION (continued) |
Total Number of All Employees Past 3 Years Year Three |
Enter year: The year associated with the employee information. |
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EMPLOYEE INFORMATION (continued) |
Total Number of All Employees Past 3 Years Total # Three |
Enter number: The total number of employees in the state, province or country. |
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EMPLOYEE INFORMATION (continued) |
% Turnover Year One |
Enter year: The year associated with the employee information. |
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EMPLOYEE INFORMATION (continued) |
% Turnover % One |
Enter percentage: The annual percentage of employee turnover. |
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EMPLOYEE INFORMATION (continued) |
% Turnover Year Two |
Enter year: The year associated with the employee information. |
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EMPLOYEE INFORMATION (continued) |
% Turnover % Two |
Enter percentage: The annual percentage of employee turnover. |
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EMPLOYEE INFORMATION (continued) |
% Turnover Year Three |
Enter year: The year associated with the employee information. |
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EMPLOYEE INFORMATION (continued) |
% Turnover % Three |
Enter percentage: The annual percentage of employee turnover. |
ACORD 188 (2003/02) 10 of 16
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Section Name |
Field Name |
Field and/or Section Description |
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Total number of employee-initiated |
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EMPLOYEE INFORMATION |
terminations in the last 3 years |
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(continued) |
Year One |
Enter year: The year associated with the employee information. |
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Total number of employee-initiated |
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EMPLOYEE INFORMATION |
terminations in the last 3 years |
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(continued) |
Total # One |
Enter number: The number of employee initiated terminations. |
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Total number of employee-initiated |
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EMPLOYEE INFORMATION |
terminations in the last 3 years |
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(continued) |
Year Two |
Enter year: The year associated with the employee information. |
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Total number of employee-initiated |
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EMPLOYEE INFORMATION |
terminations in the last 3 years |
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|
(continued) |
Total # Two |
Enter number: The number of employee initiated terminations. |
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Total number of employee-initiated |
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EMPLOYEE INFORMATION |
terminations in the last 3 years |
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|
(continued) |
Year Three |
Enter year: The year associated with the employee information. |
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Total number of employee-initiated |
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EMPLOYEE INFORMATION |
terminations in the last 3 years |
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|
(continued) |
Total # Three |
Enter number: The number of employee initiated terminations. |
|
EMPLOYEE INFORMATION |
Percentage of employees with |
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(continued) |
salaries Less than $50,000: |
Enter percentage: The percentage of employees with a salary less than $50,000. |
|
EMPLOYEE INFORMATION |
Percentage of employees with |
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|
(continued) |
salaries $50,000-$100,000: |
Enter percentage: The percentage of employees with a salary of $50,000 - $100,000. |
|
EMPLOYEE INFORMATION |
Percentage of employees with |
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(continued) |
salaries Greater Than $100,000: |
Enter percentage: The percentage of employees with a salary over $100,000. |
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EMPLOYMENT POLICY |
|
Enter text: The full name of the contact. As used here, this is the contact that has overall |
|
AND PRACTICES |
Name One |
responsibility for the human resources or personnel. |
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EMPLOYMENT POLICY |
|
Enter number: The title of the contact for the named insured. As used here, this is the |
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AND PRACTICES |
Title One |
contact that has overall responsibility for the human resources or personnel. |
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EMPLOYMENT POLICY |
|
Enter text: The full name of the contact. As used here, this is a contact for employment |
|
AND PRACTICES |
Name Two |
related incidents. |
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EMPLOYMENT POLICY |
|
Enter number: The title of the contact for the named insured. As used here, this is a |
|
AND PRACTICES |
Title Two |
contact for employment related incidents. |
ACORD 188 (2003/02) 11 of 16
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Section Name |
Field Name |
Field and/or Section Description |
|
EMPLOYMENT POLICY |
|
Enter text: The full name of the contact. As used here, this is a contact for employment |
|
AND PRACTICES |
Name Three |
related incidents. |
|
EMPLOYMENT POLICY |
|
Enter number: The title of the contact for the named insured. As used here, this is a |
|
AND PRACTICES |
Title Three |
contact for employment related incidents. |
|
EMPLOYMENT POLICY |
|
Enter text: The full name of the contact. As used here, this is a contact for employment |
|
AND PRACTICES |
Name Four |
related incidents. |
|
EMPLOYMENT POLICY |
|
Enter number: The title of the contact for the named insured. As used here, this is a |
|
AND PRACTICES |
Title Four |
contact for employment related incidents. |
|
Do you use an Employment |
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Application during your hiring |
|
|
EMPLOYMENT POLICY |
process? If Yes, answer A-D |
Check the box (if applicable): Indicates a "Yes" response to the question, "Do you use an |
|
AND PRACTICES |
below |
employment application during your hiring process?". |
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EMPLOYMENT POLICY |
|
Check the box (if applicable): Indicates a "No" response to the question, "Do you use an |
|
AND PRACTICES |
No |
employment application during your hiring process?". |
|
Does your application contain an |
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EMPLOYMENT POLICY |
employment at will statement? |
Check the box (if applicable): Indicates a "Yes" response to the question, "Does your |
|
AND PRACTICES |
Yes |
application contain an employment at will statement?". |
|
EMPLOYMENT POLICY |
|
Check the box (if applicable): Indicates a "No" response to the question, "Does your |
|
AND PRACTICES |
No |
application contain an employment at will statement?". |
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Does your application include |
|
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authorization to check references |
|
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EMPLOYMENT POLICY |
and criminal conviction records? |
Check the box (if applicable): Indicates a "Yes" response to the question, "Does your |
|
AND PRACTICES |
Yes |
application include authorization to check references and criminal conviction records?". |
|
EMPLOYMENT POLICY |
|
Check the box (if applicable): Indicates a "No" response to the question, "Does your |
|
AND PRACTICES |
No |
application include authorization to check references and criminal conviction records?". |
|
Does your application require a |
|
|
EMPLOYMENT POLICY |
signature attesting that all |
Check the box (if applicable): Indicates a "Yes" response to the question, "Does your |
|
AND PRACTICES |
representations are true? Yes |
application require a signature attesting that all representations are true?". |
|
EMPLOYMENT POLICY |
|
Check the box (if applicable): Indicates a "No" response to the question, "Does your |
|
AND PRACTICES |
No |
application require a signature attesting that all representations are true?". |
|
Does your application contain an |
|
|
EMPLOYMENT POLICY |
equal opportunity employment |
Check the box (if applicable): Indicates a "Yes" response to the question, "Does your |
|
AND PRACTICES |
statement? Yes |
application contain an equal opportunity employment statement?". |
|
EMPLOYMENT POLICY |
|
Check the box (if applicable): Indicates a "No" response to the question, "Does your |
|
AND PRACTICES |
No |
application contain an equal opportunity employment statement?". |
ACORD 188 (2003/02) 12 of 16
|
Section Name |
Field Name |
Field and/or Section Description |
|
EMPLOYMENT POLICY |
Do you distribute an employment |
Check the box (if applicable): Indicates a "Yes" response to the question, "Do you |
|
AND PRACTICES |
handbook to all employees? Yes |
distribute an employment handbook to all employees?". |
|
EMPLOYMENT POLICY |
|
Check the box (if applicable): Indicates a "No" response to the question, "Do you distribute |
|
AND PRACTICES |
No |
an employment handbook to all employees?". |
|
If Yes, does it contain an |
|
|
EMPLOYMENT POLICY |
employment-at-will statement? |
Check the box (if applicable): Indicates a "Yes" response to the question, "Does your |
|
AND PRACTICES |
Yes |
employee handbook contain an employment-at-will statement?". |
|
EMPLOYMENT POLICY |
|
Check the box (if applicable): Indicates a "No" response to the question, "Does your |
|
AND PRACTICES |
No |
employee handbook contain an employment-at-will statement?". |
|
EMPLOYMENT POLICY |
Do you have an employment |
Check the box (if applicable): Indicates a "Yes" response to the question, "Do you have an |
|
AND PRACTICES |
opportunity statement? Yes |
employment opportunity statement?". |
|
EMPLOYMENT POLICY |
|
Check the box (if applicable): Indicates a "No" response to the question, "Do you have an |
|
AND PRACTICES |
No |
employment opportunity statement?". |
|
EMPLOYMENT POLICY |
Do you have a written anti-sexual |
Check the box (if applicable): Indicates a "Yes" response to the question, "Do you have a |
|
AND PRACTICES |
harassment policy? Yes |
written anti-sexual harassment policy?". |
|
EMPLOYMENT POLICY |
|
Check the box (if applicable): Indicates a "No" response to the question, "Do you have a |
|
AND PRACTICES |
No |
written anti-sexual harassment policy?". |
|
EMPLOYMENT POLICY |
Do you have a written grievance |
Check the box (if applicable): Indicates a "Yes" response to the question, "Do you have a |
|
AND PRACTICES |
procedure? Yes |
written grievance procedure?". |
|
EMPLOYMENT POLICY |
|
Check the box (if applicable): Indicates a "No" response to the question, "Do you have a |
|
AND PRACTICES |
No |
written grievance procedure?". |
|
EMPLOYMENT POLICY |
Do you have a progressive |
Check the box (if applicable): Indicates a "Yes" response to the question, "Do you have a |
|
AND PRACTICES |
disciplinary program? Yes |
progressive disciplinary program?". |
|
EMPLOYMENT POLICY |
|
Check the box (if applicable): Indicates a "No" response to the question, "Do you have a |
|
AND PRACTICES |
No |
progressive disciplinary program?". |
|
Do you post, in places |
|
|
conspicuous to all employees and |
Check the box (if applicable): Indicates a "Yes" response to the question, "Do you post, in |
|
EMPLOYMENT POLICY |
applicants for employment, all |
places conspicuous to all employees and applicants for employment, all notices required |
|
AND PRACTICES |
notices required by law? Yes |
by law?". |
|
|
Check the box (if applicable): Indicates a "No" response to the question, "Do you post, in |
|
EMPLOYMENT POLICY |
|
places conspicuous to all employees and applicants for employment, all notices required |
|
AND PRACTICES |
No |
by law?". |
ACORD 188 (2003/02) 13 of 16
|
Section Name |
Field Name |
Field and/or Section Description |
|
EMPLOYMENT POLICY AND PRACTICES |
When requested by employees, Do you distribute information as required by federal law regarding the family medical leave act to all employees? Yes |
Check the box (if applicable): Indicates a "Yes" response to the question, "When requested by employees, do you distribute information as required by federal law regarding the family medical leave act to all employees?". |
|
|
Check the box (if applicable): Indicates a "No" response to the question, "When requested |
|
EMPLOYMENT POLICY |
|
by employees, do you distribute information as required by federal law regarding the family |
|
AND PRACTICES |
No |
medical leave act to all employees?". |
|
Do you require that all employment terminations be reviewed by the human resources |
|
|
EMPLOYMENT POLICY AND PRACTICES |
department/personnel having human resources responsibilities? Yes |
Check the box (if applicable): Indicates a "Yes" response to the question, "Do you require that all employment terminations be reviewed by the human resources department / personnel having human resources responsibilities?". |
|
|
Check the box (if applicable): Indicates a "No" response to the question, "Do you require |
|
EMPLOYMENT POLICY |
|
that all employment terminations be reviewed by the human resources department / |
|
AND PRACTICES |
No |
personnel having human resources responsibilities?". |
|
Do you provide written |
|
|
performance evaluations for all |
|
|
EMPLOYMENT POLICY |
your employees? Yes If Yes, |
Check the box (if applicable): Indicates a "Yes" response to the question, "Do you provide |
|
AND PRACTICES |
how often? |
written performance evaluations for all your employees?". |
|
EMPLOYMENT POLICY |
|
Check the box (if applicable): Indicates a "No" response to the question, "Do you provide |
|
AND PRACTICES |
No |
written performance evaluations for all your employees?". |
|
EMPLOYMENT POLICY |
|
Enter text: An explanation of a response to a general information or underwriting question. |
|
AND PRACTICES |
How often? |
Normally, "Yes" responses require an explanation. |
|
Do your supervisory employees |
|
|
receive training in the proper |
Check the box (if applicable): Indicates a "Yes" response to the question, "Do your |
|
EMPLOYMENT POLICY |
method of conducting |
supervisory employees receive training in the proper method of conducting performance |
|
AND PRACTICES |
performance appraisals? Yes |
appraisals?". |
|
|
Check the box (if applicable): Indicates a "No" response to the question, "Do your |
|
EMPLOYMENT POLICY |
|
supervisory employees receive training in the proper method of conducting performance |
|
AND PRACTICES |
No |
appraisals?". |
ACORD 188 (2003/02) 14 of 16
|
Section Name |
Field Name |
Field and/or Section Description |
|
EMPLOYMENT POLICY |
Is there a formal orientation |
Check the box (if applicable): Indicates a "Yes" response to the question, "Is there a |
|
AND PRACTICES |
program for new employees? Yes |
formal orientation program for new employees?". |
|
EMPLOYMENT POLICY |
|
Check the box (if applicable): Indicates a "No" response to the question, "Is there a formal |
|
AND PRACTICES |
No |
orientation program for new employees?". |
|
Is there a formal out-placement |
|
|
program which assists former |
Check the box (if applicable): Indicates a "Yes" response to the question, "Is there a |
|
EMPLOYMENT POLICY |
employees in obtaining alternate |
formal out-placement program which assists former employees in obtaining alternate |
|
AND PRACTICES |
employment? Yes |
employment?". |
|
|
Check the box (if applicable): Indicates a "No" response to the question, "Is there a formal |
|
EMPLOYMENT POLICY |
|
out-placement program which assists former employees in obtaining alternate |
|
AND PRACTICES |
No |
employment?". |
|
Do you use any tests for screening |
|
|
EMPLOYMENT POLICY |
applicants or for continued |
Check the box (if applicable): Indicates a "Yes" response to the question, "Do you use any |
|
AND PRACTICES |
employment? Yes |
tests for screening applicants or for continued employment?". |
|
EMPLOYMENT POLICY |
|
Check the box (if applicable): Indicates a "No" response to the question, "Do you use any |
|
AND PRACTICES |
No |
tests for screening applicants or for continued employment?". |
|
REMARKS |
Remarks |
Enter text: The general remarks associated with the employment related practices liability line of business. List any additional, pertinent information that the underwriter should know about the overall exposures of this risk. |
|
CORPORATE HISTORY |
Have you had any home or branch office closings, consolidations, layoffs/staff reduction, mergers or acquisitions within the past 24 months? If yes, please provide details |
Check the box (if applicable): Indicates a "Yes" response to the question, "Have you had any home or branch office closings, consolidations, layoffs / staff reductions, mergers or acquisitions within the past mandated period of time?". |
|
CORPORATE HISTORY |
No |
Check the box (if applicable): Indicates a "No" response to the question, "Have you had any home or branch office closings, consolidations, layoffs / staff reductions, mergers or acquisitions within the past mandated period of time?". |
|
|
Enter text: An explanation of a response to a general information or underwriting question. |
|
CORPORATE HISTORY |
Description |
Normally, "Yes" responses require an explanation. |
ACORD 188 (2003/02) 15 of 16
|
Section Name |
Field Name |
Field and/or Section Description |
|
Do you anticipate any home or |
|
|
branch office closings, |
|
|
consolidations, layoffs/staff |
|
|
reductions, mergers or |
|
|
acquisitions within the next 24 months? If yes, please provide |
Check the box (if applicable): Indicates a "Yes" response to the question, "Do you anticipate any home or branch office closings, consolidations, layoffs / staff reductions, |
|
CORPORATE HISTORY |
details. |
mergers or acquisitions with the next mandated period of time?". |
|
CORPORATE HISTORY |
No |
Check the box (if applicable): Indicates a "No" response to the question, "Do you anticipate any home or branch office closings, consolidations, layoffs / staff reductions, mergers or acquisitions with the next mandated period of time?". |
|
|
Enter text: An explanation of a response to a general information or underwriting question. |
|
CORPORATE HISTORY |
Description |
Normally, "Yes" responses require an explanation. |
|
Are you presently subject to any |
|
|
judicial or administrative order, |
|
|
decree, judgment or conciliation |
|
|
RECENT EMPLOYMENT- |
agreement relating to employment? If yes, please |
Check the box (if applicable): Indicates a "Yes" response to the question, "Are you presently subject to any judicial or administrative order, decree, judgment or conciliation |
|
RELATED ISSUES |
attach a copy. |
agreement relating to employment?". |
|
|
Check the box (if applicable): Indicates a "No" response to the question, "Are you |
|
RECENT EMPLOYMENT- |
|
presently subject to any judicial or administrative order, decree, judgment or conciliation |
|
RELATED ISSUES |
No |
agreement relating to employment?". |
|
RECENT EMPLOYMENTRELATED ISSUES |
Are you aware of any circumstances with the potential to give rise to a claim under this policy? If yes, please provide details on a separate sheet of paper. |
Check the box (if applicable): Indicates a "Yes" response to the question, "Are you aware of any circumstances with the potential to give rise to a claim under this policy?". |
|
RECENT EMPLOYMENT- |
|
Check the box (if applicable): Indicates a "No" response to the question, "Are you aware of |
|
RELATED ISSUES |
No |
any circumstances with the potential to give rise to a claim under this policy?". |
|
RECENT EMPLOYMENTRELATED ISSUES |
It is agreed that any claim(s) arising from any facts, circumstances or situations mentioned in 1,2 or 3 above are excluded from coverage (initials) |
Initial here: The named insured's initials. As used here, indicates that it is agreed that any claims arising from any facts, circumstances or situations mentioned in 1, 2, or 3 above are excluded from coverage. |
ACORD 188 (2003/02) 16 of 16
|
Section Name |
Field Name |
Field and/or Section Description |
|
ATTACHMENTS |
Employment application |
Check the box (if applicable): Indicates an employment application is attached. |
|
ATTACHMENTS |
Employee Disciplinary Procedures |
Check the box (if applicable): Indicates the employee disciplinary procedures are attached. |
|
ATTACHMENTS |
Employee Grievance Procedures |
Check the box (if applicable): Indicates the employee grievance procedures are attached. |
|
ATTACHMENTS |
Employee handbook/manual |
Check the box (if applicable): Indicates the employee handbook / manual is attached. |
|
ATTACHMENTS |
Employee Performance evaluation forms |
Check the box (if applicable): Indicates the employee performance evaluation is attached. |
|
ATTACHMENTS |
EEO and sexual harassment policy |
Check the box (if applicable): Indicates the equal employment opportunities (EEO) and sexual harassment policy is attached. |
|
ATTACHMENTS |
Out placement program |
Check the box (if applicable): Indicates the outplacement program is attached. |
|
ATTACHMENTS |
Latest EEO-1 |
Check the box (if applicable): Indicates the latest EEO-1 is attached. |
|
ATTACHMENTS |
Latest Annual report |
Check the box (if applicable): Indicates the latest annual report is attached. |
|
ATTACHMENTS |
Other |
Check the box (if applicable): Indicates there is an attachment other than those listed. |
|
ATTACHMENTS |
Describe Other |
Enter text: The description of the attachment. |
|
SIGNATURES |
Name |
Enter text: The full name of the contact. As used here, this is the individual responsible for human resources function. |
|
SIGNATURES |
Signature |
Sign here: Accommodates the signature of the applicant or named insured. As used here, this is the individual responsible for human resources function. |
|
SIGNATURES |
Date |
Enter date: The date the form was signed by the named insured. As used here, this is the individual responsible for human resources function. |
|
SIGNATURES |
Name |
Enter text: The full name of the contact. As used here, this is the president or chairman. |
|
SIGNATURES |
Signature |
Sign here: Accommodates the signature of the applicant or named insured. As used here, this is the president or chairman. |
|
SIGNATURES |
Date |
Enter date: The date the form was signed by the named insured. As used here, this is the president or chairman. |
|
REMARKS |
Remarks |
Enter text: The general remarks associated with the employment related practices liability line of business. List any additional, pertinent information that the underwriter should know about the overall exposures of this risk. |
|
Edition |
Date |
The edition identifier of the form including the form number and edition (the date is typically formatted YYYY/MM). |
|