Office Pkg. and Prof Liab
Fields marked (*) are mandatory.
General Information
Name of Insured
Address
City
State
Zip
Business Phone
Fax Number
Email Address
Web Site Address
Home Phone
Property Questions
Age of building/Year Built:
Type of building construction:
Number of stories
Other occupancies
Square feet you occupy (sq. ft.)
If the building is over 25 years old, please answer the following:
Year Electricity was updated
Is it on circuit breakers?
Year Plumbing was updated
Copper or Galvanized plumbing?
Other plumbing
Year Building was last re-roofed
Type of roofing material
Type of heating system in the building
Protective Devices
Burglar Alarm
Central Station or local alarm?
Name of alarm company
Is the building sprinklered?
Are there smoke detectors?
Liability Questions
Please provide Information on previous insurance carrier
Previous Ins. Carrier
Policy number
Prior premium
Policy renewal date
Please provide information about your business:
Years in business
Projected Gross annual receipts
Projected annual payroll
Describe your business, product or service
Coverage Limits
Building
Contents (equipment, inventory, supplies, etc.)
Deductible
Loss of Income
Money and Securities
Glass or signs
General Liability Limit
Non-owned and Hired Automobile Liability
Is liquor liability needed?
If Glass Coverage is needed, please provide dimensions:
Please list other coverages you may need:
Miscellaneous Information
Name of Additional Insured (Landlord or vendor)
Mailing Address
City
State
Zip
Practice Information
Check each that applies to your practice
Individual
Partnership
Association
Group Practice
Professional Corporation
Affiliation
Other
Current Professional Liability Coverage
Current Insurance Carrier
Limits of liability
per claim
aggregate
Effective Date
Premium
Retroactive Date
Professional Information
Occupation
Specialty
Practice Operates
Board Certified
Claims History
This information is kept strictly confidential
Claim #1
Claim Status
Claimant Name
Date of occurrence
Insurance Carrier
Location of occurrence
Allegations
Amount paid on your behalf
Amount reserved on behalf
Claim #2
Claim Status
Claimant Name
Date of occurrence
Insurance Carrier
Location of occurrence
Allegations
Amount paid on your behalf
Amount reserved on behalf
Additional Comments
Please give any additional comments you feel
appropriate for this quotation. If you have
additional information where there was not
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