Get Application For Employee Benefits Liability Coverage - Claims Made

This guide provides a step-by-step approach to filling out the Application for Employee Benefits Liability Coverage - Claims Made online. By following these instructions, you can ensure that all necessary information is accurately submitted.

Follow the steps to complete your application effectively.

1. Select the ‘Get Form’ button to access the form and open it for completion.
2. In section I, enter the name of the applicant. Provide the complete address, including the street, city, state, and zip code.
3. Indicate the total number of employees located in the U.S. If there are employees stationed outside the U.S. or in Canada, specify the location and number at each location.
4. In section 4, choose the desired limits for coverage by checking the appropriate box that corresponds to your needs.
5. For section 5, check all applicable employee benefits programs you offer along with the year each program was first introduced. Also, list any additional benefit programs that you want to be considered for coverage.
6. Answer section 6 by detailing any employee benefit losses that have occurred or are pending in the last five years.
7. In section 7, disclose any knowledge of events that could lead to future claims under this insurance, including a description.
8. State whether your organization has a full-time Human Resources Department and indicate the number of personnel in that department.
9. Specify who employees can consult regarding questions about their Employee Benefit Program by selecting from the options provided.
10. Answer section 10 about whether a signed acceptance or rejection from each employee is required for programs offering enrollment options.
11. Indicate if a benefit brochure or written explanation of the Employee Benefits Program is provided to each employee and if the employee acknowledges receipt in writing.
12. List any prior carriers and policy numbers. Note if prior coverage was on a claims-made basis and provide effective dates.
13. State if the applicant is subject to the Employee Retirement Income Security Act of 1974 (ERISA) and if they have Fiduciary Liability Insurance. Include relevant details.
14. List any existing Commercial Lines policy numbers and effective dates with Employers Mutual Companies, or state 'none' as applicable.
15. Set the proposed effective date for the policy. Ensure your name and signature are included to validate the application.
16. After completing all sections, you can save changes, download a copy, print the form, or share it as needed.

Complete your application for employee benefits liability coverage online today!