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Professional
Liability and/or General Liability Insurance Quote Request |
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ABOUT THE OWNER / PRINCIPAL |
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Company Name:
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First Name:
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Last Name: |
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Address: |
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City: |
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State: |
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Phone: |
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| Zip Code: |
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E-mail: |
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Confirm E-mail: |
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ABOUT THE BUSINESS |
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Business Structure: |
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Location: |
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| Description of Business: |
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Year Started: |
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Years experience in industry: |
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| Tax ID # |
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| What percentage
of your business is conducted at a hospital or nursing home? |
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PROFESSIONAL LIABILITY
(E&O) SECTION |
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Professional Liability Limits: |
$
($250,000 will be quoted if nothing is entered) |
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| Full Time Employees: |
(including
owners)
Part-Time:
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Full Time independent contractors: |
Part-Time:
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| What
types of clients do you service? If you treat disorders, please list
them here: |
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For what types of
professionals are you seeking insurance?
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(examples: nutritionist, 1 part time; masseuses, 2 full time) |
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| Do you belong to
any professional associations? |
(if known) |
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Gross Receipts: |
Prior Year $
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Current
Year $
(if new business, write NEW and estimate an amount) |
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Estimates for Next
Year $
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| Annual Payroll: |
$
(if none, write "none") |
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| Claims: |
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| Other: |
Do your customers sign a
contract or written agreement
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COMMERCIAL GENERAL LIABILITY SECTION |
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General Liability Limits: |
$
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Space Occupied (sq feet): |
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Building Security System? |
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PROPERTY INSURANCE -
OPTIONAL |
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| Business personal property
and equipment? |
(office equipment, supplies, furniture) (we can quote
coverage for inventory and food spoilage based on your industry) |
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Year Building Built: |
(estimate is
acceptable) |
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Building Insurance? |
(tenant improvement coverage, or for the building) |
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Do you currently have insurance (if
yes, with what carrier?
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Current Premium:
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Do you have any other information
about your business, or comments that you would like to
share? Please place special requests here, such as extra coverage
for special items. |
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NO COVERAGE IS BOUND,
OFFERED, ISSUED THROUGH THIS ELECTRONIC COMMUNICATION, ALL POLICIES MUST BE
UNDERWRITTEN AND APPROVED BY THE CARRIER. DO NOT CANCEL YOUR CURRENT
INSURANCE. |
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Copyright 2012 Stratum
Insurance Agency, LLC |
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