Carolina Casualty Insurance Company
4600 Touchton Road East, Building 100, Suite 400, Jacksonville, FL 32246
Proposal Form
Employment Practices Liability Insurance
CLAIMS MADE WARNING FOR APPLICATION
THIS PROPOSAL FORM IS FOR A CLAIMS MADE POLICY, RELATING TO CLAIMS MADE AGAINST THE
INSUREDS DURING THE POLICY PERIOD OR EXTENDED REPORTING PERIOD, IF APPLICABLE.
EPL 24505 (rev. 01-06)
Page 1 of 4
Whenever printed in this Proposal Form, the terms in boldface type shall have the same meanings as indicated in the Policy. This Proposal Form is
to be completed with respect to the entire Insured Entity. Insured Entity as used herein is defined to include the Named Insured and any
Subsidiaries.
Name of Named Insured
Street Address
Suite
City
County
State
Zip Code
Website Address (if applicable)
Federal Employer Identification Number (FEIN)
The Officer designated as agent of the Insured Entity and of all Insureds to receive any and all notices from the Insurer or their authorized
representatives concerning this insurance:
Contact Name
Title
E-mail Address
Telephone Number
Fax Number
Producer Information
Submitted by (Agency Name)
Dated
Agent’s Name (Individual’s Name)
Agent’s License Number
Current Insurance Information (Provide details to all “Yes” answers by attachment)
1.
Provide the following information regarding the Insured Entity’s most recent insurance policies. If “None”, so state.
Type of Policy
Insurance Carrier
Expiration Date
Limit of Liability
Deductible
Premium
Directors and Officers Liability: None
$
$
$
Employment Practices Liability: None
$
$
$
General Liability: None
$
$
$
2.
Has the Extended Reporting Period (or Discovery Period) been exercised for the Insured Entity’s most recent
Employment Practices Liability insurance policy?
Yes No
3.
Within the last 3 years, has any Directors and Officers Liabil