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Office Package Professional Liability Quote Form

 
Combo: Office Package Professional Liability Insurance Quote
We would like to provide you with a free, no-obligation insurance quote. Please provide as much information possible for the most accurate quote. This information will be kept confidential and will be used for quote purposes only.

General Information
Name of Insured:
Address:
City:   State:   Zip:
Business Phone:   Fax Number:
Email Address:
Web Site Address: http://
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?:

Yes   No
Year Plumbing was updated:

Copper or Galvanized plumbing?:

Copper   Galvanized   Other:

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?:
Y   N
  Central Station
 Local Alarm
Y   N
Y   N

 

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?
$
$
$
Yes   No
    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
Group Practice		 Partnership
Professional Corporation		 Association
Affiliation		 Other: 

 

Current Professional Liability Coverage
Current Insurance Carrier:
Limits of liability: $ per claim       $ aggregate
Effective Date:   Retroactive Date:
Premium: $

 

Professional Information
Occupation:
Specialty:
Practice Operates:
Board Certified
Full Time Part Time
Yes No

 

Claims History
This information is kept strictly confidential

Claim #1
   Claim Status: Closed   Open
Claimant Name:   Date of occurrence:
Insurance Carrier:   Location of occurrence: 
Allegations:
Amount paid on your behalf: $   Amount reserved on behalf: $

Claim #2
   Claim Status: Closed   Open
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 enough fields above, please enter them here.


Please click on the "Submit Quote" button to send your quote request.
One of our representatives will respond to your submission as soon as possible.

   

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