Management Practices Liability Insurance "QuickQuote"

A.  Basic Information:
1.  Company Name:
2.  Company Address: 
    

3.  Company Telephone Number:
4.  Number of Locations:
5.  Principal States in which you operate:
6.  Number of Years in business:
7.  Your Name:
8.  Your Title:

9.  Your E-Mail:

B.  Total Number of:
1.  Office/Sales Employees:
2.  Full-Time Delivery Employees:
3.  Part-Time Delivery Employees:
4.  Full-Time Independent Contractors:
5.  Part-Time Independent Contractors:

C.  Human Resource Management Practices
     (note: you do not need to answer "Yes" to qualify)

1. Designated Manager of Human Resources?   Yes   No
2. Employee Handbook distributed to all EE's?   Yes   No
3. Formal Policy against Sexual Harrassment?   Yes   No
4. Formal Policy against Discrimination?             Yes   No
5. FMLA Policy (Family Medical Leave Act)?              Yes   No
6. ADA Policy (Americans with Disabilities Act)?       Yes   No
7. Procedure for Reporting Complaints?             Yes   No

D.  Layoff/Turnover Issues

1. Compared to other local delivery services, my turnover is:
    Lower   Similar   Higher

2. Other than normal turnover, do you anticipate layoffs in the
    next 12 months?   Yes   No

3. Other than normal turnover, have you had any layoffs in the
    last 12 months?   Yes   No

E.  Loss Information  (prior losses will not disqualify you from coverage)

1. Are you aware of any facts, incidents, or circumstances which
    may result in claims being made against you under this policy?
   Yes   No

    If "Yes" please provide details below:
  

2. Have there been past losses where indemnity (damages) and/or
    legal expenses combined exceeded $5,000 involving: wrongful
    termination, discrimination, sexual harassment, and other work-
    place torts, both state and federal, civil and administrative?
   Yes   No           If "No," click here to continue.

   If "Yes," provide the following for each incident:
     a. Claim Date:
     b. Claimant Name:
     c. Nature of Claim:
     d. Defense Cost:  $
     e. Indemnity (Damages) Amount:  $
     f.  Amount of Claim Reserve:  $
     g. Claim Status:  Open   Closed   
    If this is your only claim, click here to continue.

     aa. Claim Date:
     bb. Claimant Name:
     cc. Nature of Claim:
     dd. Defense Cost:  $
     ee. Indemnity (Damages) Amount:  $
     ff.  Amount of Claim Reserve:  $
     gg. Claim Status:  Open   Closed   

 Any other claims?  If so, briefly describe:
 

D.  Coverage and Deductible Options:  (select up to two of each)

1. Coverage Limits (per claim & aggregate)
    $250,000 $500,000 $1,000,000 $3,000,000 $5,000,000

2. Deductible Options
    $2,500 $5,000 $10,000 $25,000

3. KBS Program Included Features:
      Covers claims brought by contractors:  
      Covers claims brought by customers: 
      Covers acts committed prior to policy:
      Covers intentional acts: 
      Covers punitive damages: 
      Insured has right to approve settlements: 
      Insured has conditional right to select attorneys: 
      NO Coinsurance payments apply: 
      FREE Kit (hard copy/disk) with model policies and procedures 

Thank you for your cooperation.  We will respond to you soon!

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