Page 1 of 6
ELH-APP (4-02)
Employment Practices Liability Insurance
Indication Form
Please fax or mail to:
NAMIC Insurance Agency
3601 Vincennes Road, Indianapolis, IN 42268
Fax: 317-872-5636 / Phone: 800-336-2642
All questions must be answered. If a question does not apply, indicate “N/A.”
GENERAL INFORMATION
1. Name (This is the name of the firm or the parent/holding company): ____________________________________________
____________________________________________________________________________________________________________________
2. Address: __________________________________________________________________________________________________________
City: _____________________________________________________ State:_______________________ Zip Code: _____________
Additional Locations: _____________________________________________________________________________________________
3. Business Type: Corporation
Partnership
Professional Corporation
Sole Proprietorship Other (specify): ___________________________________________________
4. a. Date Business Established:___________________________________________________________________________________
b. Describe Nature of Business: _________________________________________________________________________________
________________________________________________________________________________________________________________
5. a. Are you in bankruptcy or contemplating any form of bankruptcy? ......................................... Yes No
b. Do you have positive net worth and sufficient working capital? ............................................. Yes No
6. Complete the following for any subsidiaries more than 50% owned by you that you want covered. Include
these employees in Question #11:
Name
Location
Nature of Business
% of
Interest
Date
Acquired/
Established
# of
Employees
7. With r