ACORD 188 (2014/12) - EMPLOYMENT RELATED PRACTICES LIABILITY SECTION
ACORD 188 (2014/12) - EMPLOYMENT RELATED PRACTICES LIABILITY SECTION
ACORD 188, Employment Related Practices Liability Section, is used to apply for Employment Related Practices Liability coverage.
This form should be used in conjunction with ACORD 125, Commercial Insurance Application, Applicant Information Section.
Form Page 1
Section Name
Field Name
Description
IDENTIFICATION
Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g., agency or
brokerage).
IDENTIFICATION
Date
Enter date: The date on which the form is completed. (MM/DD/YYYY)
IDENTIFICATION
Agency
Enter text: The full name of the producer / agency.
IDENTIFICATION
Policy Number
Enter identifier: The identifier assigned by the insurer to the policy, or submission, being
referenced exactly as it appears on the policy, including prefix and suffix symbols. If required for
self-insurance, the self-insured license or contract number.
IDENTIFICATION
Carrier
Enter text: The insurer's full legal company name(s) as found in the file copy of the policy. Use
the actual name of the company within the group to which the policy has been issued. This is
not the insurer's group name or trade name.
IDENTIFICATION
NAIC Code
Enter code: The identification code assigned to the insurer by the NAIC.
IDENTIFICATION
Applicant / First Named
Insured
Enter text: The named insured(s) as it / they will appear on the policy declarations page.
IDENTIFICATION
Proposed Effective Date
Enter date: The effective date of the policy. The date that the terms and conditions of the policy
commence. (MM/DD/YYYY)
IDENTIFICATION
Proposed Expiration Date
Enter date: The date on which the terms and conditions of the policy will expire. (MM/DD/YYYY)
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.
COVERAGE
Limit of Liability ($)
Enter amount: The limit for liability coverage.
COVERAGE
Co-Payment AMT ($)
Enter amount: The co-payment amount.
COVERAGE
Other
Enter text: The description of any other pertinent information required by the insurer.
INSURANCE INFORMATION
1. 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.
ACORD 188 (2014/12) rev. 04-29-2014
Page 1 of 13
INSURANCE INFORMATION
Telephone
Enter number: The telephone number of the person the insurer is to contact regarding any
potential claims inquiries.
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.
INSURANCE INFORMATION
Fax
Enter number: The fax number of the person the insurer is to contact regarding any potential
claims inquiries.
INSURANCE INFORMATION
2. 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?.
INSURANCE INFORMATION
No
Check the box (if applicable): Indicates a No response to the question, Do you currently carry
ERPL Insurance?.
INSURANCE INFORMATION
If Yes, Insurer:
Enter text: The name of the previous insurer.
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.
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.
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.
INSURANCE INFORMATION
Limit One
Enter limit: The limit amount of the prior coverage. As used here, this refers to your ERPL
Insurance.
INSURANCE INFORMATION
Deductible One
Enter deductible: The deductible amount of the prior coverage. As used here, this refers to your
ERPL Insurance.
INSURANCE INFORMATION
% Co-Pay One
Enter amount: The co-payment amount. As used here, this refers to your ERPL Insurance.
INSURANCE INFORMATION
Retro Date One
Enter date: The retroactive date for the policy being described. As used here, this refers to your
ERPL Insurance.
INSURANCE INFORMATION
Insurer One
Enter text: The name of the previous insurer. As used here, this refers to your ERPL Insurance.
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.
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.
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.
INSURANCE INFORMATION
Limit Two
Enter limit: The limit amount of the prior coverage. As used here, this refers to your ERPL
Insurance.
ACORD 188 (2014/12) rev. 04-29-2014
Page 2 of 13
INSURANCE INFORMATION
Deductible Two
Enter deductible: The deductible amount of the prior coverage. As used here, this refers to your
ERPL Insurance.
INSURANCE INFORMATION
% Co-Pay Two
Enter amount: The co-payment amount. As used here, this refers to your ERPL Insurance.
INSURANCE INFORMATION
Retro Date Two
Enter date: The retroactive date for the policy being described. As used here, this refers to your
ERPL Insurance.
INSURANCE INFORMATION
Insurer Two
Enter text: The name of the previous insurer. As used here, this refers to your ERPL Insurance.
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.
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.
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.
INSURANCE INFORMATION
Limit Three
Enter limit: The limit amount of the prior coverage. As used here, this refers to your ERPL
Insurance.
INSURANCE INFORMATION
Deductible Three
Enter deductible: The deductible amount of the prior coverage. As used here, this refers to your
ERPL Insurance.
INSURANCE INFORMATION
% Co-Pay Three
Enter amount: The co-payment amount. As used here, this refers to your ERPL Insurance.
INSURANCE INFORMATION
Retro Date Three
Enter date: The retroactive date for the policy being described. As used here, this refers to your
ERPL Insurance.
INSURANCE INFORMATION
Insurer Three
Enter text: The name of the previous insurer. As used here, this refers to your ERPL Insurance.
INSURANCE INFORMATION
Policy Period - Eff Date Four
Enter date: The effective date of the prior policy.
INSURANCE INFORMATION
Policy Period - Exp Date
Four
Enter date: The expiration date of the previous coverage.
INSURANCE INFORMATION
Premium Four
Enter amount: The annual modified premium charged (not including taxes or service charges)
for the specified line of business.
INSURANCE INFORMATION
Limit Four
Enter limit: The limit amount of the prior coverage.
INSURANCE INFORMATION
Deductible Four
Enter deductible: The deductible amount of the prior coverage.
INSURANCE INFORMATION
% Co-Pay Four
Enter amount: The co-payment amount.
INSURANCE INFORMATION
Retro Date Four
Enter date: The retroactive date for the policy being described.
INSURANCE INFORMATION
Insurer Four
Enter text: The name of the previous insurer.
INSURANCE INFORMATION
Policy Period - Eff Date Five
Enter date: The effective date of the prior policy.
ACORD 188 (2014/12) rev. 04-29-2014
Page 3 of 13
INSURANCE INFORMATION
Policy Period - Exp Date
Five
Enter date: The expiration date of the previous coverage.
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.
INSURANCE INFORMATION
Deductible Five
Enter deductible: The deductible amount of the prior coverage.
INSURANCE INFORMATION
% Co-Pay Five
Enter amount: The co-payment amount.
INSURANCE INFORMATION
Retro Date Five
Enter date: The retroactive date for the policy being described.
INSURANCE INFORMATION
Insurer Five
Enter text: The name of the previous insurer.
INSURANCE INFORMATION
Policy Period Eff Date Six
Enter date: The effective date of the prior policy.
INSURANCE INFORMATION
Policy Period Exp Date Six
Enter date: The expiration date of the previous coverage.
INSURANCE INFORMATION
Premium Six
Enter amount: The annual modified premium charged (not including taxes or service charges)
for the specified line of business.
INSURANCE INFORMATION
Limit Six
Enter limit: The limit amount of the prior coverage.
INSURANCE INFORMATION
Deductible Six
Enter deductible: The deductible amount of the prior coverage.
INSURANCE INFORMATION
% Co-Pay Six
Enter amount: The co-payment amount.
INSURANCE INFORMATION
Retro Date Six
Enter date: The retroactive date for the policy being described.
INSURANCE INFORMATION
Insurer Six
Enter text: The name of the previous insurer.
EMPLOYEE INFORMATION
State One
Enter code: The state or province code where the employees are located.
EMPLOYEE INFORMATION
Country One
Enter code: The country code where the employees are located.
EMPLOYEE INFORMATION
Number of Locations One
Enter number: The number of locations in the state, province, or country.
EMPLOYEE INFORMATION
Total number of employees
One
Enter number: The total number of employees in the state, province or country.
EMPLOYEE INFORMATION
State Two
Enter code: The state or province code where the employees are located.
EMPLOYEE INFORMATION
Country Two
Enter code: The country code where the employees are located.
EMPLOYEE INFORMATION
Number of Locations Two
Enter number: The number of locations in the state, province, or country.
EMPLOYEE INFORMATION
Total number of employees
Two
Enter number: The total number of employees in the state, province or country.
EMPLOYEE INFORMATION
State Three
Enter code: The state or province code where the employees are located.
ACORD 188 (2014/12) rev. 04-29-2014
Page 4 of 13
EMPLOYEE INFORMATION
Country Three
Enter code: The country code where the employees are located.
EMPLOYEE INFORMATION
Number of Locations Three
Enter number: The number of locations in the state, province, or country.
EMPLOYEE INFORMATION
Total number of employees
Three
Enter number: The total number of employees in the state, province or country.
EMPLOYEE INFORMATION
State Four
Enter code: The state or province code where the employees are located.
EMPLOYEE INFORMATION
Country Four
Enter code: The country code where the employees are located.
EMPLOYEE INFORMATION
Number of Locations Four
Enter number: The number of locations in the state, province, or country.
EMPLOYEE INFORMATION
Total number of employees
Four
Enter number: The total number of employees in the state, province or country.
EMPLOYEE INFORMATION
State Five
Enter code: The state or province code where the employees are located.
EMPLOYEE INFORMATION
Country Five
Enter code: The country code where the employees are located.
EMPLOYEE INFORMATION
Number of Locations Five
Enter number: The number of locations in the state, province, or country.
EMPLOYEE INFORMATION
Total number of employees
Five
Enter number: The total number of employees in the state, province or country.
EMPLOYEE INFORMATION
Subsidiaries Name One
Enter text: The name of the subsidiary of the company. This may also contain owned
foundations or charitable trusts.
EMPLOYEE INFORMATION
State One
Enter code: The state or province code where the employees are located.
EMPLOYEE INFORMATION
Country One
Enter code: The country code where the employees are located.
EMPLOYEE INFORMATION
Total number of employees
One
Enter number: The total number of employees in the state, province or country.
EMPLOYEE INFORMATION
Subsidiaries Name Two
Enter text: The name of the subsidiary of the company. This may also contain owned
foundations or charitable trusts.
EMPLOYEE INFORMATION
State Two
Enter code: The state or province code where the employees are located.
EMPLOYEE INFORMATION
Country Two
Enter code: The country code where the employees are located.
EMPLOYEE INFORMATION
Total number of employees
Two
Enter number: The total number of employees in the state, province or country.
EMPLOYEE INFORMATION
Subsidiaries Name Three
Enter text: The name of the subsidiary of the company. This may also contain owned
foundations or charitable trusts.
EMPLOYEE INFORMATION
State Three
Enter code: The state or province code where the employees are located.
EMPLOYEE INFORMATION
Country Three
Enter code: The country code where the employees are located.
ACORD 188 (2014/12) rev. 04-29-2014
Page 5 of 13
EMPLOYEE INFORMATION
Total number of employees
Three
Enter number: The total number of employees in the state, province or country.
EMPLOYEE INFORMATION
Subsidiaries Name Four
Enter text: The name of the subsidiary of the company. This may also contain owned
foundations or charitable trusts.
EMPLOYEE INFORMATION
State Four
Enter code: The state or province code where the employees are located.
EMPLOYEE INFORMATION
Country Four
Enter code: The country code where the employees are located.
EMPLOYEE INFORMATION
Total number of employees
Four
Enter number: The total number of employees in the state, province or country.
EMPLOYEE INFORMATION
Total Number of U.S.
Employees Full Time
Enter number: The number of full time employees in the USA.
EMPLOYEE INFORMATION
Total Number of U.S.
Employees Part Time:
Enter number: The number of part time employees in the USA.
EMPLOYEE INFORMATION
Total Number of U.S.
Employees Temporary:
Enter number: The number of temporary employees in the USA.
EMPLOYEE INFORMATION
Total Number of U.S.
Employees Seasonal:
Enter number: The number of seasonal employees in the USA.
EMPLOYEE INFORMATION
Total number of fair labor
standards act exempt
employees
Enter number: The number of fair labor standards act exempt employees.
EMPLOYEE INFORMATION
Total number of fair labor
standards act non-exempt
employees
Enter number: The number of fair labor standards act non-exempt employees.
EMPLOYEE INFORMATION
Total number of unionized
employees in the USA
Enter number: The number of unionized employees in the USA.
EMPLOYEE INFORMATION
Total Number of Non- U.S.
Employees Full Time:
Enter number: The number of full time employees outside the USA.
EMPLOYEE INFORMATION
Total Number of Non- U.S.
Employees Part Time:
Enter number: The number of part time employees outside the USA.
EMPLOYEE INFORMATION
Total Number of Non- U.S.
Employees Temporary:
Enter number: The number of temporary employees outside the USA.
EMPLOYEE INFORMATION
Total Number of Non- U.S.
Employees Seasonal:
Enter number: The number of seasonal employees outside the USA.
ACORD 188 (2014/12) rev. 04-29-2014
Page 6 of 13
EMPLOYEE INFORMATION
Total Number of All
Employees Past 3 Years -
Year One
Enter year: The year associated with the employee information.
EMPLOYEE INFORMATION
Total Number of All
Employees Past 3 Years
Total # - One
Enter number: The total number of employees in the state, province or country.
EMPLOYEE INFORMATION
Total Number of All
Employees Past 3 Years -
Year Two
Enter year: The year associated with the employee information.
EMPLOYEE INFORMATION
Total Number of All
Employees Past 3 Years
Total # - Two
Enter number: The total number of employees in the state, province or country.
EMPLOYEE INFORMATION
Total Number of All
Employees Past 3 Years -
Year Three
Enter year: The year associated with the employee information.
EMPLOYEE INFORMATION
Total Number of All
Employees Past 3 Years
Total # - Three
Enter number: The total number of employees in the state, province or country.
EMPLOYEE INFORMATION
% Turnover - Year One
Enter year: The year associated with the employee information.
EMPLOYEE INFORMATION
% Turnover - One
Enter percentage: The annual percentage of employee turnover.
EMPLOYEE INFORMATION
% Turnover - Year Two
Enter year: The year associated with the employee information.
EMPLOYEE INFORMATION
% Turnover - Two
Enter percentage: The annual percentage of employee turnover.
EMPLOYEE INFORMATION
% Turnover - Year Three
Enter year: The year associated with the employee information.
EMPLOYEE INFORMATION
% Turnover - Three
Enter percentage: The annual percentage of employee turnover.
EMPLOYEE INFORMATION
Total number of
employee-initiated
terminations in the last
three (3) years - Year One
Enter year: The year associated with the employee information.
EMPLOYEE INFORMATION
Total number of
employee-initiated
terminations in the last
three (3) years - Total # One
Enter number: The number of employee-initiated terminations.
ACORD 188 (2014/12) rev. 04-29-2014
Page 7 of 13
EMPLOYEE INFORMATION
Total number of
employee-initiated
terminations in the last
three (3) years - Year Two
Enter year: The year associated with the employee information.
EMPLOYEE INFORMATION
Total number of
employee-initiated
terminations in the last
three (3) years - Total # Two
Enter number: The number of employee-initiated terminations.
EMPLOYEE INFORMATION
Total number of
employee-initiated
terminations in the last
three (3) years - Year Three
Enter year: The year associated with the employee information.
EMPLOYEE INFORMATION
Total number of
employee-initiated
terminations in the last
three (3) years - Total #
Three
Enter number: The number of employee-initiated terminations.
EMPLOYEE INFORMATION
Percentage of employees
with salaries less than
$50,000:
Enter percentage: The percentage of employees with a salary less than $50,000.
EMPLOYEE INFORMATION
Percentage of employees
with 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 salaries greater than
$100,000:
Enter percentage: The percentage of employees with a salary over $100,000.
Form Page 2
Section Name
Field Name
Description
IDENTIFICATION
Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g., agency or
brokerage).
EMPLOYMENT POLICY AND
PRACTICES
Name One
Enter text: The full name of the contact. As used here, this is the contact that has overall
responsibility for the human resources or personnel.
EMPLOYMENT POLICY AND
PRACTICES
Title One
Enter number: The title of the contact for the named insured. As used here, this is the contact
that has overall responsibility for the human resources or personnel.
ACORD 188 (2014/12) rev. 04-29-2014
Page 8 of 13
EMPLOYMENT POLICY AND
PRACTICES
Name Two
Enter text: The full name of the contact. As used here, this is a contact for employment related
incidents.
EMPLOYMENT POLICY AND
PRACTICES
Title Two
Enter number: The title of the contact for the named insured. As used here, this is a contact for
employment related incidents.
EMPLOYMENT POLICY AND
PRACTICES
Name Three
Enter text: The full name of the contact. As used here, this is a contact for employment related
incidents.
EMPLOYMENT POLICY AND
PRACTICES
Title Three
Enter number: The title of the contact for the named insured. As used here, this is a contact for
employment related incidents.
EMPLOYMENT POLICY AND
PRACTICES
Name Four
Enter text: The full name of the contact. As used here, this is a contact for employment related
incidents.
EMPLOYMENT POLICY AND
PRACTICES
Title Four
Enter number: The title of the contact for the named insured. As used here, this is a contact for
employment related incidents.
EMPLOYMENT POLICY AND Employment Application
PRACTICES
3. Do you use an
during your hiring process?
If Yes, answer A-D
Enter Y for a Yes response. Input N for No response. Indicates the response to the
question, Do you use an employment application during your hiring process?.
EMPLOYMENT POLICY AND
PRACTICES
3A. Does your application
contain an employment at
will statement?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Does your application contain an employment at will statement?.
EMPLOYMENT POLICY AND
PRACTICES
3B. Does your application
include authorization to
check references and
criminal conviction
records?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Does your application include authorization to check references and criminal conviction
records?.
EMPLOYMENT POLICY AND require a signature attesting
PRACTICES
3C. Does your application
that all representations are
true?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Does your application require a signature attesting that all representations are true?
EMPLOYMENT POLICY AND contain an equal
PRACTICES
3D..Does your application
opportunity employment
statement?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Does your application contain an equal opportunity employment statement?.
EMPLOYMENT POLICY AND
PRACTICES
4. Do you distribute an
employment handbook to all
employees?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Do you distribute an employment handbook to all employees?.
ACORD 188 (2014/12) rev. 04-29-2014
Page 9 of 13
EMPLOYMENT POLICY AND
PRACTICES
4A. If Yes, does it contain
an employment-at-will
statement?
Enter Y for a Yes response. Input N for No response. Indicates the response to the
question, Does your employee handbook contain an employment-at-will statement?.
EMPLOYMENT POLICY AND
PRACTICES
5. Do you have an
employment opportunity
statement?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Do you have an employment opportunity statement?.
EMPLOYMENT POLICY AND
PRACTICES
6. Do you have a written
anti-sexual harassment
policy?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Do you have a written anti-sexual harassment policy?.
EMPLOYMENT POLICY AND 7. Do you have a written
PRACTICES
grievance procedure?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Do you have a written grievance procedure?
EMPLOYMENT POLICY AND
PRACTICES
8. Do you have a
progressive disciplinary
program?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Do you have a progressive disciplinary program?.
EMPLOYMENT POLICY AND
PRACTICES
9. Do you post, in places
conspicuous to all
employees and applicants
for employment, all notices
required by law?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Do you post, in places conspicuous to all employees and applicants for employment, all notices
required by law?
EMPLOYMENT POLICY AND distribute information as
PRACTICES
10. When requested by
employees, do you
required by federal law
regarding the family medical
leave act to all employees?
Enter Y for a Yes response. Input N for No response. Indicates the 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?
EMPLOYMENT POLICY AND reviewed by the human
PRACTICES
11. Do you require that all
employment terminations be
resources department /
personnel having human
resources responsibilities?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Do you require that all employment terminations be reviewed by the human resources
department / personnel having human resources responsibilities?
EMPLOYMENT POLICY AND
PRACTICES
12. Do you provide written
performance evaluations for
all your employees?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Do you provide written performance evaluations for all your employees?
EMPLOYMENT POLICY AND
PRACTICES
How often?
Enter text: An explanation of the frequency in which written performance evaluations are
provided for all your employees.
ACORD 188 (2014/12) rev. 04-29-2014
Page 10 of 13
EMPLOYMENT POLICY AND
PRACTICES
13. Do your supervisory
employees receive training
in the proper method of
conducting performance
appraisals?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Do your supervisory employees receive training in the proper method of conducting
performance appraisals?
EMPLOYMENT POLICY AND
PRACTICES
14. Is there a formal
orientation program for new
employees?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Is there a formal orientation program for new employees?
EMPLOYMENT POLICY AND
PRACTICES
15. Is there a formal
out-placement program
which assists former
employees in obtaining
alternate employment?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Is there a formal out-placement program which assists former employees in obtaining alternate
employment?
EMPLOYMENT POLICY AND
PRACTICES
16. Do you use any tests for
screening applicants or for
continued employment?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Do you use any tests for screening applicants or for continued employment?
CORPORATE HISTORY
1. 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
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Have you had any home or branch office closings, consolidations, layoffs / staff reductions,
mergers or acquisitions within the past 24 months?
CORPORATE HISTORY
Description
Enter text: An explanation of any home or branch office closings, consolidations, layoffs / staff
reduction, mergers or acquisitions within the past 24 months.
CORPORATE HISTORY
2. 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
details.
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Do you anticipate any home or branch office closings, consolidations, layoffs / staff reductions,
mergers or acquisitions within the next 24 months?
CORPORATE HISTORY
Description
Enter text: An explanation of any anticipated home or branch office closings, consolidations,
layoffs / staff reductions, mergers or acquisitions within the next 24 months.
ACORD 188 (2014/12) rev. 04-29-2014
Page 11 of 13
RECENT
EMPLOYMENT-RELATED
ISSUES
2. Are you presently subject
to any judicial or
administrative order,
decree, judgment or
conciliation agreement
relating to employment? If
yes, please attach a copy.
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Are you presently subject to any judicial or administrative order, decree, judgment or
conciliation agreement relating to employment?
RECENT
EMPLOYMENT-RELATED
ISSUES
3. 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.
Enter Y for a Yes response. Input N for No response. Indicates the response to the
question, Are you aware of any circumstances with the potential to give rise to a claim under
this policy?
RECENT
EMPLOYMENT-RELATED
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.
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.
Form Page 3
Section Name
Field Name
Description
IDENTIFICATION SECTION
Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g., agency or
brokerage).
ATTACHMENTS
Employment Application
Check the box (if applicable): Indicates an employment application is attached.
ATTACHMENTS
Employee Grievance
Procedures
Check the box (if applicable): Indicates the employee grievance procedures are attached.
ATTACHMENTS
Employee Performance
Evaluation Forms
Check the box (if applicable): Indicates the employee performance evaluation form is attached.
ATTACHMENTS
Outplacement Program
Check the box (if applicable): Indicates the outplacement program is attached.
ATTACHMENTS
Latest Annual Report
Check the box (if applicable): Indicates the latest annual report is attached.
ACORD 188 (2014/12) rev. 04-29-2014
Page 12 of 13
ATTACHMENTS
Employee Disciplinary
Procedures
Check the box (if applicable): Indicates the employee disciplinary procedures are attached.
ATTACHMENTS
Employee Handbook /
Manual
Check the box (if applicable): Indicates the employee handbook / manual 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
Latest EEO-1
Check the box (if applicable): Indicates the latest EEO-1 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. (MM/DD/YYYY) 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. (MM/DD/YYYY) As used here,
this is the president or chairman.
SIGNATURE SECTION
Producer's Signature
Sign here: Accommodates the signature of the authorized representative (e.g., producer, agent,
broker, etc.) of the company(ies) listed on the document. This is required in most states.
SIGNATURE SECTION
Producers Name
Enter text: The name of the authorized representative of the producer, agency and/or broker
that signed the form.
SIGNATURE SECTION
State Producer License
Number
Enter identifier: The State License Number of the producer.
SIGNATURE SECTION
Applicant's Signature
Sign here: Accommodates the signature of the applicant or named insured.
SIGNATURE SECTION
Date
Enter date: The date the form was signed by the named insured. (MM/DD/YYYY)
SIGNATURE SECTION
National Producer Number
Enter identifier: The National Producer Number (NPN) as defined in the National Insurance
Producer Registry (NIPR). Note: The NPN is not the same as the producer state license
number.
ACORD 188 (2014/12) rev. 04-29-2014
Page 13 of 13