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Practice
Information
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Full
Name:
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Contact
Person:
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Address:
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(include
all buildings and/or suite numbers; attach separate sheet if necessary
or for convenience) |
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City:
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State:
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Zip:
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County:
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Phone:
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Fax:
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E-mail:
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Best
contact time:
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Federal
Tax ID Number:
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Current
Coverage Information
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Professional
Liability Carrier:
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Renewal
Date:
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Property
& Business Owner Carrier:
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Renewal
Date:
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Worker
Compensation Carrier:
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Renewal
Date:
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Group
Health Carrier:
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Renewal
Date:
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Disability
Carrier:
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Renewal
Date:
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General
Information
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Practice
is:
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Specialty:
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Own
or rent building/space?
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Is
building a condominium?
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How
many building/property/casualty losses have you had in the last
five years?
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Details
(attach separate sheet if necessary):
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Professional
Liability Insurance
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1.
Current Limits:
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2.
Type of coverage:
claims-made
occurrence
other
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3.
How many paid claims have you had in the last 10 years?
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4.
Any open claims?
yes
no
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Please
attach any available information on paid or open claims, i.e.,
open date, close date, amount paid, reserves, allegations, etc.
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Property
Information
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Estimated replacement value of clinical/office equipment you own?
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Estimated replacement value of clinical/office equipment you lease?
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What year was/were the building(s) constructed?
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4.
Type of construction (select all that apply):
EXTERIOR:
Frame
(wood)
Frame/brick cover
Concrete (no wood)
Steel/Metal siding
Steel/sprayed masonry
Steel/masonry
Steel/all glass
FLOOR:
Wood
Steel & concrete
Concrete
ROOF:
Wood
Wood
with steel
Steel only
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5.
Functional interior sprinkler system:
yes
no
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Are you required to have flood insurance?
yes
no |
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Is there a body of water within 100 feet of your building?
yes
no |
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Closest fire station?
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Closest fire hydrant?
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Real
Estate Information
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How many floors in your building?
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Total square feet of building?
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Percentage of building you occupy:
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4.
If you own the building, is it owned under the same name as the
practice?
yes
no
If
not, under what name is the building owned?
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What is the current replacement value of the building?
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Commercial
Automobile
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Number of automobiles registered in the name of the practice or
group:
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2.
Please list year, make and model for each automobile:
year
make
model |
3.
Please list the social security/drivers license number for each
driver.
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Worker
Compensation
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Annual payroll (excluding officers and owners/shareholders):
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2.
Will you cover officers and owners in the worker's compensation
plan?
yes
no
If
incorporated, how many officers?
If
not incorporated, how many owners?
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3.
Do you test employees for latex allergies?
yes
no
If
employees test positive for latex allergy, do you supply non-latex
gloves?
yes
no
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Other
Coverages
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What
else can we help you with?
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