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Employment Practices Liability Insurance Quote

Number of Physicians:                            Number of Non-Physician Employees:      Do you have a human resources department, manual and/or equivalent written procedures? Yes No Has your organization ever been involved in any grievance or administrative hearing before the following agencies or under any of the following acts? National Labor Relations Board, Equal Employment Opportunity Commission, Civil Rights Act of 1991, Age Discrimination in Employment Act, Americans with Disabilities Act, or any other governmental agency or act. Yes No If yes, please give a brief explanation Applicant Name Contact Name: Organization: Address: City: State:    Zip: Phone: Fax: Email Address: How do you wish to be contacted? Mail Phone Email Fax Best time to be contacted during working hours? Have you spoken with a representative from our company?   Yes No If so, who? How did you hear about us? If other, please explain:   Requested information