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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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