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LAST MILE DELIVERY
Employment P r a c ti c e s Liability
A p p l i c a ti o n
Employment Practices Liability Insurance Application Last Mile
Company Name: Mailing Address: Year Company Established:
Federal Tax ID: Website:
FedEx Ground P&D Amazon Prime Linehaul
USPS Mail Delivery Appliance Delivery (with Installation)
Last Mile Sectors (check all that apply for this entity)
FedEx Ground Linehaul
XPO Logistics
FedEx Ground Custom Critical JB Hunt Final Mile
DHL Delivery Contractor
LSO Final Mile
USPS Linehaul
Bison Expediter
Courier Services
Ceva Logistics
Auto Parts Distribution
Food & Beverage Distribution
Amazon Prime P&D
OnTrac Delivery
RX/Medical Equip Delivery Other:
Number of Employees by State
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NC
ND
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
1. Has the applicant been involved in any merger, acquisition, and/or asset sale in the past 18 months? Yes No If yes, please explain:
2. Does applicant have any actual or potential earn-out or other contingent payment obligation in the next
24 months to any person or entity where such payment obligation exceeds $500,000?
Yes No
If yes, please explain:
3. If Applicant has current EPLI coverage has any claims be filed, claims payments made or policynon-
renewed in the last 36 months? Yes
No
If yes, please explain:
4. In the last 36 months has Applicant in their capacity as an employee, officer, or director of the Applicant or another entity been the subject of or involved in any:
a. Litigation, civil, arbitration, administrative or criminal proceeding, civil or criminal charge or
hearing, or a written demand seeking monetary or non-monetary damages? Yes
No
b. Formal or informal investigation, proceeding or inquiry by any federal, state or local
governmental agency or regulatory body, including without limitation, the U.S. Department of
c.
Justice, the U.S. Department of Labor, or any federal or state office of the Attorney General? Notice of charges or other proceeding from the Equal employment Opportunity Commission or
Yes
No
any similar state or local agency or regulatory body? Yes
No
If yes to any of these please provide details on a Supplemental page at the end of the application.
5. Within the last 3 years, has the Applicant had any commercial crime losses?
Yes
No
If yes, please explain:
6. Applicants total number of Employees-full time, part time, seasonal and contracted (leased, independent or otherwise). *Note-count only 50% of the part time and seasonal employees for the total.
7. How many employees annual pay is over $100,000?
8. Have more than 25% of the officers or management voluntarily left the employ of the Applicant or had
employment with the Applicant terminated within the last 18 months? Yes
No
9. Does the Applicant anticipate a reduction in force greater than 20% in the next 12 months? Yes
No
10. Does the Applicant publish and distribute an employee handbook to everyemployee?
Yes
No
11. Are there written procedures for handling employee complaints of discrimination or sexual harassment
or other types of employment grievance or complaints?
Yes
No
12. Would the Applicant want Unlimited phone and email access to personalized advice & best practice
counsel on over 50 different human resources and employment law issues from a national law firm at
no additional cost?
Yes
No
13. If applicable currently has an EPLI policy, please provide the following:
Name of Company
Limit of Insurance
Expiration Date
Premium
Person Completing Application: Applicant Signature:
Date:
SUBMIT
Question #:
Supplemental Page
Question #: Question#:
................
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