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LYNDON SOUTHERN INSURANCE COMPANYReturn All Applications to:EMPLOYMENT PRACTICESLIABILITY INSURANCEAPPLICATIONRockwood Programs Inc.3001 Philadelphia PikeClaymont, DE 19703-2580Tel: 800-558-8808 Fax: 302-764-5477www.rockwoodinsurance.comTHIS APPLICATION IS FOR A CLAIMS-MADE POLICY. PLEASE READ YOUR POLICY CAREFULLYApplicant may qualify for a QUICK QUOTE by completing Section I below. Sections II, III, IV, & V answerswill be required prior to binding and are subject to underwriting approval. QUICK QUOTE is not availablefor accounts with losses in the past 5 years. If there is a loss history, please complete the entire applicationand submit details in a Claim Supplement.I GENERAL INFORMATIONA. Applicant/Named InsuredB. Physical AddressO Same as mailing address(P.O. Box is not an applicable address)CityStateZipC. Web AddressCountyPhone (D. Primary Contact: Email Address)E. Description of OperationsF. Business is: O CorporationG. Full timePartTimeO Individual Proprietor O Partnership O LLC O Other H. What percentage of employees belong to a Union . . . . . . . . . . .I. List below the Number of Employees in Top 3 States by State:Number ofNumber of1. StateEmployees2. StateEmployeesJ. Number of Locations: Within U.S. . . . . . . . . .II UNDERWRITING INFORMATIONA. Year Established . . . . . . . . . . . . . . . . .Volunteer/InternsEmployees Outside the U.S.Number of3. StateEmployeesOutside the U.S. . . . . . . . . .Number of years under current management . . . . . . . .B. Do more than 50% of all employees currently earn more than 100,000? . . . . . . . . . . . . . . . . . . . . . . . . . .1. Is the Applicant a Subsidiary of another organization? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2. Is the Applicant a franchisee of another organization? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .O Yes O NoO Yes O NoO Yes O No3. Name of Parent and/or Franchisor and Location:4. Does the Applicant want any Subsidiary(s) covered? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .If “Yes,” include employees in employee count above and provide:a) Name of Subsidiary(s)b) Is the Subsidiary(s) at least 50% owned by the Applicant? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .c) Does the Subsidiary(s) fall within the same class of business as the Applicant? . . . . . . . . . . . . . . . .5. Expiring PolicyRetroactive DateExpiration DateLSIC-1001-MO 0919////Limits Retention O Yes O NoO Yes O NoO Yes O NoPremium Carrier:Rockwood EPLI Ap Page 1 of 6
III HUMAN RESOURCESA. Written Guideline Requirements:1. Does each entity proposed for Insurance have a written Email/Internet Policy currently in place or iswilling to implement one? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .O Yes O No2. Does each entity proposed for insurance have a written Anti-Discrimination and Anti-HarassmentPolicy? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3.4.O Yes O NoDoes the company have an employee grievance reporting and resolution process? . . . . . . . . . . . . . . O Yes O NoDoes the company have a HR Coordinator? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . O Yes O NoIf “No”, describe how HR functions are administered.5. Do all employees receive training in the proper implementation of your human resources policiesand procedures? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . O YesIf “Yes,” please provide a description and number of hours each employees is required to take.6. Do you have a written policy with respects to progressive discipline for Employees. . . . . . . . . . . . . . O Yes7. If you have a public website, does it comply with the Web Content Accessibility Guidelines . . . . . . . O Yes(WCAG) 2.0?8. Do you have procedures in place to deal with biometric privacy laws? . . . . . . . . . . . . . . . . . . . . . . . . O YesNY Applicants Only: Is your organization in compliance with the Gender Expression . . . . . . . . . . . . . O YesNon-Discrimination Act?9. Is any Family and Medical Leave (FMLA) provided gender-neutral? . . . . . . . . . . . . . . . . . . . . . . . . . . O YesO NoO NoO NoO NoO NoO NoIV BUSINESS PRACTICESA. 1. Has any entity proposed for insurance closed, sold, merged-with or acquired any company in thepast 12 months or anticipate doing so in the next 12 months? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . O Yes O No2. Has any entity proposed for insurance downsized, laid off, or reduced staff in the past 12 months oranticipate doing so in the next 12 months? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . O Yes O NoIf “Yes,” please complete the following three questions.a) What percentage of the workforce was/will be affected? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . %b) How and why were the individuals selected? Provide details on separate sheet of paper.c) What will be offered? (Check all that apply):O Re-location arrangements O Re-training O Severance package O Out-placementB. Do you own any other entities? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . O YesIf “Yes”, please provide details on Supplemental Application.O NoNoV CLAIMS HISTORYA. Within the last 5 years, has any employment related, or third party discrimination, or third party harassment inquiry,complaint, notice of hearing, claim, or suit been made against any entity proposed for insurance or any personproposed for Insurance in the capacity of either Director, Officer, Member (if an LLC), or Employee of any entityproposed for insurance. . . . . . . O Yes O No If “Yes,” complete Claim Supplemental for each claim.B. Is any person proposed for this Insurance aware of any fact, circumstance, or situation which may result in anemployment claim, or third party discrimination, or third party harassment claim against any entityproposed for Insurance or any of its Directors, Officers, Members (if LLC), or Employees? . . . . . . . . . . . O Yes O NoIf “Yes,” complete Claim Supplemental for each claim.LSIC-1001-MO 0919Rockwood EPLI Ap Page 2 of 6
VI OPTIONAL COVERAGESA. Are you looking for Wage and Hour coverage? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . O YesIf “Yes”, please complete Wage and Hour supplemental application.B. Are you looking for Third Party coverage? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . O YesC. Are you looking for Defense Outside the Limits of Liability Coverage? . . . . . . . . . . . . . . . . . . . . . . . O YesO NoO NoO NoVII ADDITIONAL APPLICANT INFORMATIONApplicant’sMailing AddressCityLSIC-1001-MO 0919StateZipRockwood EPLI Ap Page 3 of 6
FRAUD STATEMENTSto contain materially false information concerning any fact material thereto; or conceals, for the purpose of misleading, informationconcerning any fact material thereto may be guilty of a crime andmay be subject to fines and confinement in prison.Kentucky Fraud Statement: Any person who knowingly and withintent to defraud any insurance company or other person files anapplication for insurance containing any materially false informationor conceals, for the purpose of misleading, information concerningany fact material thereto commits a fraudulent insurance act, whichis a crime.Maine Fraud Statement: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for thepurpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits. A binder may not bewithdrawn but a prospective notice of cancellation may be sent andcoverage denied for fraud or material misrepresentation in obtainingcoverage. A policy may not be unilaterally rescinded or voided.Maine and Washington Fraud Statement: It is a crime to knowingly provide false, incomplete or misleading information to aninsurance company for the purpose of defrauding the company.Penalties may include imprisonment, fines or denial of insurancebenefits. A binder may not be withdrawn but a prospective notice ofcancellation may be sent and coverage denied for fraud or materialmisrepresentation in obtaining coverage. A policy may not be unilaterally rescinded or voided.Maryland Fraud Statement: Any person who knowingly or willfullypresents a false or fraudulent claim for payment of a loss or benefitor who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to finesand confinement in prison.Minnesota Notice: Authorization or agreement to bind the insurance may be withdrawn or modified only based on changes to theinformation contained in this application prior to the effective dateof the insurance applied for that may render inaccurate, untrue orincomplete any statement made with a minimum of 10 days noticegiven to the insured prior to the effective date of cancellation whenthe contract has been in effect for less than 90 days or is being canceled for nonpayment of premium.New Jersey Fraud Statement: Any person who included any falseor misleading information on an application for an insurance policyis subject to criminal and civil penalties.New York Disclosure Notice: This policy is written on a claimsmade basis and shall provide no coverage for claims arising out ofincidents, occurrences or alleged Wrongful Acts or Wrongful Employment Acts that took place prior to retroactive date, if any, statedon the declarations. This policy shall cover only those claims madeagainst an insured while the policy remains in effect for incidentsreported during the Policy Period or any subsequent renewal of thisPolicy or any extended reporting period and all coverage under thepolicy ceases upon termination of the policy except for the automatic extended reporting period coverage unless the insured purchasesadditional extended reporting period coverage. The policy includesan automatic 60 day extended claims reporting period following theLSIC-1001-MO 0919Rockwood EPLI Ap Page 4 of 6
FRAUD STATEMENTS Continued . . .Utah Notice: I understand that Punitive Damages are not insurable in the state of Utah. There will be no coverage afforded forPunitive Damages for any Claim brought in the State of Utah. Anycoverage for Punitive Damages will only apply if a Claim is filed ina state which allows punitive or exemplary damages to be insurable. This may apply if a Claim is brought in another state by a subsidiary or additional location(s) of the Named Insured, outside thestate of Utah, for which coverage is sought under the same policy.Utah Fraud Statement: Any person, who with intent to defraud orknowing that he is facilitating a fraud against an insurer, submits anapplication or files a claim containing a false or deceptive statementis guilty of insurance fraud.Vermont Fraud Statement: Any person who knowingly presents afalse or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance maybe subject to fines and confinement in prison.Virginia Notice: This Policy is written on a claims-made basis.Please read the policy carefully to understand your coverage. Youhave an option to purchase a separate limit of liability for the extended reporting period. If you do not elect this option, the limitof liability for the extended reporting period shall be part of the andnot in addition to limit specified in the declarations. If you have anyquestions regarding the cost of an extended reporting period, pleasecontact your insurance company or your insurance agent. Statements in the supplication shall be deemed the insured’s representations. A statement made in the application or in any affidavit madebefore or after a loss under the policy will not be deemed material orinvalidates coverage unless it is clearly proven that such statementwas material to the risk when assumed and was untrue.Virginia Fraud Statement: Any person who knowingly and withintent to defraud an insurer, submits an Application for insuranceor files a claim containing a false or deceptive statement is guilty ofinsurance fraud.Washington Fraud Statement: It is a crime to knowingly providefalse, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties mayinclude imprisonment, fines or a denial of insurance benefits.Fraud Statement (All Other States): Any person who knowinglypresents a false or fraudulent claim for payment of a loss or benefitor knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.Missouri & Rhode Island Disclosure Notice: I understand and acknowledge that if a 100,000 or 250,000 Limit of Liability is chosen or if the Insured’s Organization has more than 200 employees,that Defense Costa are a part of the Limit of Liability. This meansthat Defense Costs will reduce my limits of insurance and may exhaust them completely and should that occur, I shall be liable forany further legal Defense Costs and Damages. Defense Costa is asdefined in Section III.LSIC-1001-MO 0919Rockwood EPLI Ap Page 5 of 6
I also understand that the Limit of Liability for the Extended Reporting Period, if applicable, shall be a part of andnot in addition to the limit specified in the Policy Declarations.If your state requires that we have information regarding you Authorized Retail Agent or Broker, please provide below.Retail agency nameAgent’s signatureEmail AddressLicense No.Phone No. ((Required in New Hampshire))Agency mailing addressCityState ZipThe signer of this application acknowledges and understands that the information provided in this Application is material to the Insurer’s decision to provide the requested insurance and is relied on by the Insurer in providing such insurance. The signer of this application representsthat the information provided in this Application is true and correct in all matters. The signer of this Application further represents that anychanges in matter inquired about in this Application occurring prior to the effective date of coverage, which render the information providedherein untrue, incorrect or inaccurate in any way will be reported to the insurer immediately in writing. The Insurer reserves the right to modifyor withdraw any quote or binder issued if such changes are material to the insurability or premium charged, based on the Insurer’s underwriting guides. The Insurer is hereby authorized, but not required, to make any investigation and inquiry in connection with the information,statements and disclosures provided in the Application. The decision of the Insurer not to make or to limit any investigation or inquiry shallnot be deemed a waiver of any rights by the Insurer and shall not estop the Insurer from relying on any statement in this Application in theevent the Policy is issued. It is agreed that this Application shall be the basis of the contract should a policy be issued and it will be attachedand become a part of the Policy.New York Fraud Statement: Any person who knowingly and with intent to defraud any insurance company or other person files an applicationfor 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 also be subject to a civil penalty not to exceedfive thousand dollars and the state value of the claim for each such violation.Applicant’sSignatureTitlePresident, Chairperson of the Board, Managing Member or Executive DirectorDateLicense No.Retail agency namePhone No. ( )Agent’s signature(Required in New Hampshire)Email AddressAgency mailing addressCityLSIC-1001-MO 0919StateZipRockwood EPLI Ap Page 6 of 6
THIS APPLICATION IS FOR A CLAIMS-MADE POLICY. PLEASE READ YOUR POLICY CAREFULLY . I. List below the Number of Employees in Top 3 States by State: Employees Outside the U.S. . LYNDON SOUTHERN INSURANCE COMPANY LSIC-1001-MO 0919. III HUMAN RESOURCES A. Written Guideline Requirements: 1. Does each entity proposed for Insurance have a written .
