Form

Practice Information

Legal Entity Name:*

DBA Name:

Phone number*

Entity Type (ex: LLC, sole prop., corp., etc.)*

Years in business:*

Contact Person:*

Email*

Mailing Address*

Location (if different):

Number of Employees*

Annual Payroll: *

Annual Revenue*

Has insurance been cancelled/non-renewed in the last three (3) years?*

Have you had any losses in past 3 Years on any of the office coverages?*

If yes, details of claims in the last three (3) years:

Please complete the sections of coverages below to receive a non-binding indication:

General Liability Only

Provides general liability coverage. NO PROPERTY COVERAGE INCLUDED.

Square Footage You Occupy:

Business Owner's

Provides general liability coverage AND property coverage (building/contents).

**If you have more than 1 location, please complete the information for each location.

If you own your building:

Building Value (at reconstruction cost)

Building Square Footage:

Contents Amount (without computers):

Computers amount:

Tenant Improvements/Betterments (value of the improvements that you are responsible for):

Building Construction:

Square Footage You Occupy:

No. of Stories:

Year Built:

Sprinkler System?

Additional Coverage

Flood Insurance

Commercial Umbrella

Excess policy over your primary policies (business owner's and workers' compensation).

Limit of Liability requested:

Workers' Compensation

Covers accidents or diseases resulting from job-related incidents.

"Estimated" Workers' Compensation Gross Payroll (employees only):

# of Employees

Full Time

Part Time

Federal ID #

Cyber Liability

Coverage for privacy breaches occurring through the means of electronic or paper files that lead to identity theft. An application will be required for indication.

Cyber liability

Regulatory Risk/Medefense

Defense costs, civil fines and penalties coverage for RAC Audits, HIPAA, Stark Law and EMTALA proceedings. An application will be required for indication.

Regulatory risk/Medefense

Amount of ERISA Bond:

(Maximum bond $500,000 – 3 year premium: $450)

DMEPOS (Surety Bond)

This bond is for suppliers with Medicare for durable medical equipment, prosthetics, orthotics, and supplies.

Amount of Bond:

($50k per location–approximate annual premium $250. Application will be required for approval)

I acknowledge that the information provided on this questionnaire is accurate to the best of my knowledge.*

Additional Coverage:

Employment Practice Liability Insurance (EPLI) – (provides coverage for alleged wrongful acts arising from employment-related claims; wrongful termination, discrimination, sexual harassment, etc.) An application will be required for an indication.