Combo: Office Pkg. and Professional Liability

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General Information
Name of Business*
Address*
Street AddressAddress Line 2CityStateZIP Code
Business Phone*
Fax
Email Address*
Website Address
Contact Name
FirstLast
Property Questions
Age of Building/Year Built:
Type of Building Construction
Number of Stories
Other Ouccupancies
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?
- No
- Yes
Year Plumbing Was Updated
Copper or Galvanized Plumbing?
- Copper
- Galvanized
- Other
Other Plumbing
Year Building Was Last Re-roofed
Type of Roofing Material
Type of Heating System in The Building
Protective Devices
Burglar Alarm
- No
- Yes
Central Station or Local Alarm?
- Central Station
- Local Alarm
Name of Alarm Company
Is The Building Sprinkled?
- No
- Yes
Are There Smoke Detectors?
- No
- Yes
Liability Questions
Please Provide Information on Previous Insurance Carrier
Previous Ins. Carrier
Policy Number
Prior Premium
Policy Renewal Date
MM
DD
YYYY
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?
- No
- Yes
If Glass Coverage Is Needed, Please Provide Dimensions:
Please List Other Coverages You May Need
Miscellaneous Information
Name of Additional Insured (Landlord or Vendor)
FirstLast
Mailing Address
Street AddressAddress Line 2CityStateZIP Code
Practice Information
Please check each that applies to your practice
Please check each that applies to your practice
- Individual
- Partnership
- Association
- Group Practice
- Professional Corporation
- Affiliation
- Other
Other
Current Professional Liability Coverage
Current Insurance Carrier
Limits of Liability
Per Claim
Aggregate
Effective Date
MM
DD
YYYY
Professional Information
Occupation
Specialty
Practice Operates
- Full Time
- Part Time
Board Certified
- No
- Yes
Claims History
This information is kept strictly confidential
Claim Status: Claim #1
- Closed
- Open
Claimant Name
FirstLast
Date of Occurance
MM
DD
YYYY
Insurance Carrier
Location of Occurance
Allegations
Amount Paid on Your Behalf
Amount Reserved on Your Behalf
CLAIM #2 Claim Status:
- Closed
- Open
Claimant Name
FirstLast
Date of Occurance
MM
DD
YYYY
Insurance Carrier
Location of Occurance
Allegations
Amount Paid on Your Behalf
Amount Reserved on Your Behalf
Additional Comments
Please add any additional comments you feel appropriate for this quotation. If you have any additional information where there was not enough room in the fields above, please include it below.

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Combo: Office Pkg. and Professional Liability

General Information

Property Questions

If The Building Is Over 25 Years Old, Please Answer The Following:

Protective Devices

Liability Questions

Please Provide Information About Your Business

Coverage Limits

Miscellaneous Information

Practice Information

Current Professional Liability Coverage

Limits of Liability

Professional Information

Claims History

Additional Comments

Recent Blog Posts

Connect With Us

Contact Us