| Personal Information |
| First Name
Required
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| Last Name
Required
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| Corporate Name
Optional
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| Primary Phone Number
Required
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| Fax
Optional
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| E-Mail Address
Required
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| Mailing Address
Optional
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| City
Required
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| State
Optional
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| ZIP / Postal Code
Required
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| Date of Birth
Optional
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| FEIN or SSN
Optional
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| Business Information |
| Requested Effective Date
Optional
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| Year Business was started
Optional
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| Entity Type
Optional
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| Have you had any property or general liability claims in the past 3 years?
Optional
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| If yes, please explain and included date of loss and settlement amount
Optional
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| Have you been declined, non-renewed or cancelled for property insurance in the past 3 years?
Optional
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| If yes, please explain when and by whom
Optional
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| Please provide the following information, if applicable |
| Loss payee
Optional
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| Address
Optional
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| City, State. ZIP Code
Optional
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| Additional named insured
Optional
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| Address
Optional
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| City, State. ZIP Code
Optional
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| Mortgagee
Optional
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| Address
Optional
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| City, State. ZIP Code
Optional
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| Premises Information |
| Building owner, if different from the applicant
Optional
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| Address
Optional
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| City, State. ZIP Code
Optional
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| Years at this location
Optional
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| Are you the
Optional
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| Year the building was built
Optional
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| Total Square foot of building
Optional
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| Total Square foot occupied by your business
Optional
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| Number of stories the building has
Optional
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| Are any parts of the building residential?
Optional
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| Building Contruction Type
Optional
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| What type of roof is on the building
Optional
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| If the building is over 25 years old, please provide the year following items were updated |
| Plumbing
Optional
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| Wiring
Optional
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| Heat/Air
Optional
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| Roof
Optional
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| Does the building have a fire protection sprinkler system?
Optional
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| Do you have a fire alarm?
Optional
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| If yes, is it local or monitored? Please specify by whom
Optional
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| Do you have a burglar alarm?
Optional
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| If yes, is it local or monitored? Please specify by whom
Optional
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| What exposures are adjacent to your location? |
| Property to the right?
Optional
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| Property to the left?
Optional
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| Property to the rear?
Optional
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| Coverage Information |
| Property Deductible
Optional
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| How many employees at this location?
Optional
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| What was your annual payroll for 2008-2009
Optional
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| What were your total receipts for 2008-2009
Optional
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| What is the name of the Retirement Plan for your practice?
Optional
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| Estimate the total cost to replace Business Personal Property |
| Total Number of operatories
Optional
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| Furniture & Fixtures: waiting room, office furniture, operatory equipment, etc.
Optional
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| Electronic Equipment: telephone system, computer hardware & software, etc.
Optional
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| Instruments & Supplies: hand instruments, medical supplies, office supplies, etc.
Optional
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| Improvements & Betterments i.e. lease hold improvements. Typically for leased or rented spaces
Optional
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| TOTAL
Optional
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| Estimate the total cost to replace the building |
| Additional Buildings on premises: storage buildings, garages, shed, etc.
Optional
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| Reconstruction Cost of Building, not the market value
Optional
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| Date
Optional
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| Initial
Required
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Submission Validation Required |
Enter the Validation Code from above.
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