On-line Employment Practices Liability Insurance

Thank you for considering our on-line employment practices liability insurance service.   Because Greater National Group is an insurance broker, not an insurance company, we will process your application with major insurance companies in order to find the right employment practices liability insurance for you.

Please fill in the following form as fully as possible, then click 'submit' at the end of the form.
You can use the TAB key to move to the next field. We will respond with your terms as soon as we have researched the market for the right available deals that fit your requirements.

Employer Details
1a. Name of Employer:
1b. Trading name(s):
2. Principal address:
3. Nature of business (including subsidiaries):
4. Date the Employer commenced the business (as referred to above):
5. Legal status of the Employer: Listed Private Sole Trader Unlisted
Partnership Co-op/Mutual Other
If other, please specify:
Employee Details
6. Total personnel numbers as at 30th June:
Personnel Category Est This Year: Last Year: Previous Year:
Total Personnel
7. Please state the annual number of staff turnover
8. Please state the number of employees in the following salary ranges:
$0 - $35,000
$35,001 - $100,000
Over $100,000
Employment Practices Details
9. Did the Employer trade profitably (net of tax) in the last 2 years?
Yes No
10. Did the Employer initiate any termination/s of employment of any staff within the last 2 years?
Yes No
If Yes please state the reason for the termination/s and the number of full-time and part-time employees terminated:
11. Did the Employer have any office closures, consolidations, mergers or acquisitions in the last 2 years resulting in termination of employment of any staff?
Yes No
If Yes please state the reason for the termination/s and the number of full-time and part-time employees terminated:
12. Does the Employer anticipate any of the events referred to in questions 10 and 11 above happening in the next 18 months?
Yes No
If Yes please provide details:
13. Are employment policies and procedures that have been reviewed and approved by an external consultant in place?
Yes No
If Yes when?
14. Are employment application forms used during the hiring process?
Yes No
15. Are reference check made of incoming employees and contractors?
Yes No
16. Are employment handbooks distributed to all employees?
Yes No
17. Are written workplace policies in place regarding the following matters?
17a. equal opportunity
Yes No
17b. sexual harassment
Yes No
17c. discrimination
Yes No
17d. procedures to be followed before the termination of employment of any staff member
Yes No
18. Are documented procedures in place to facilitate resolution of a complaint raised by an employee?
Yes No
Claim Details
19. Have there been any claims made by or on behalf of a staff member against the Employer in the last 3 years?
Yes No
If Yes please provide details:
Limit of Indemnity Details
20. Limit of indemnity required: $500,000 $1,000,000 Other
If other, please specify:
Optional Extensions
21. Please confirm whether you require Reinstatement of Aggregate Limit. Cover is limited to one reinstatement and an additional premium will be charged.
Yes No
22. For the purpose of computing the Stamp Duty of the insurance, please provide us with a breakdown of numbers of employees of the Corporation applicable to each State, Territory and Overseas.
%  %  %  %  %  %  %  %  %

Duty of Disclosure:
Are you aware of any matters not disclosed above that is relevant to the underwriter's consideration of this insurance?
Yes No
If so, please provide details:
I/We hereby declare that:
My/Our attention has been drawn to the Important Notices accompanying this form and further I/we have read these notices carefully and acknowledge my/our understanding of their content. The above statements are true, and I/we have not suppressed or mis-stated any facts and should any information given by me/us alter between the date of this form and the inception date of the insurance to which this relates I/we shall give immediate notice thereof. I/We authorise GNG and the Insurer to collect or disclose any personal information about another individual (for example, an employee, or client), I/we declare that the individual has been or will be made aware of that fact and the Privacy Policy. I/We also confirm that I/we am/are authorised to act for and on behalf of all persons who may be entitled to indemnity under any policy which may be issued pursuant to this form and I/we complete this form on their behalf.
Any other comments, requests or relevant information you need to add:
Contacting you about your quote:
In order to select the most appropriate cover for you, it may be important to discuss quote details in person. Please leave a contact phone number and best time to call to facilitate this.
Your full name:
Company/Business/Name of Applicant to be Insured:
Your phone number (please include area code):
Your mobile phone number:
Best time(s) to call:
Please send my quote by (select at least one):
email phone fax mail
Your email address:
Your website address:
Your fax number:
Your postal address: