General Information
Business Name:
Contact Name:
Address:
City:   State:   Zip:
Business Phone:   Cell Phone:   Fax:
Contact Email Address:
Business Web Address:
Business Type:     Years in Business:
Federal ID/EIN #:


Current Insurance Information
Company Name (not agency):
Policy Expiration Date:   Premium Amount: $
Years with Company:
NCCI Number:
NCCI Experience Modification Number:
What type of coverages do you currently have:
Bond
Commercial Auto
Commercial Liability
Commercial Property		 Commercial Umbrella
Directors & Officers Liability
Disability
Group Health		 Group Life
Professional Liability
Other  


About Your Business
# of full-time
employees
# of part-time
employees
How long
in business
How many
locations
Estimated Annual
Payroll
years
$
Please give a brief description of your business (below):


Additional Business Information
Do you have any losses in the past 3 years?: Yes No
Do you have Independent Contractors?: Yes No
If yes, how many?:
Do paychecks reflect the above name?: Yes No
If no, please provide details:
Federal Tax TD:
Type: Corporation Partnership
Individual    Other
Average hourly wage for non-physician employees: $ / hour
List all Officers/Partners
Name: Title: % Ownership: Excluded/Included:
What is the business specialty?
Off premise operations: Yes No


Employee Information
Employee#
Classification code
Estimate Yearly Payroll
1
2
3
4
5
Please list additional employees in the "Additional Comments" section below

 
Claims History
Enter all claims or occurrences that may give rise to claims for the prior 3 years.
This information is kept strictly confidential

Claim #1
   Claim Status: Closed   Open
Date of Occurrence:   Date of Claim:
Type/Description of Occurrence or Claim:
Amount paid on your behalf: $   Amount reserved on behalf: $

Claim #2
   Claim Status: Closed   Open
Date of Occurrence:   Date of Claim:
Type/Description of Occurrence or Claim:
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 space, please enter them here.


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