Request for Employment Practice Liability Quote

Entity Name:

Mailing Address:

City:

State:

Zip Code:

Physical Address: (If different from mailing address)

City:

State:

Zip Code:

In the next 12 months (or during the past 24 months) are you contemplating (or have you completed or been in the process of completing) the following:

Any actual or proposed merger, acquisition, or divesture?

Any creation of a new business, subsidiary, or division?

Any registration for a public offering or a private placement of securities (stocks or bonds)?

Any reorganization or arrangement with creditors under federal or state law?

Any branch, location, facility, officer, or subsidiary closing, consolidations, or layoffs?

If yes to any question, please provide information: