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General Information

Name(Required)
Address
Legal Entity
MM slash DD slash YYYY
Insurance coverage requested
MM slash DD slash YYYY
MM slash DD slash YYYY
MM slash DD slash YYYY

Property Details

Are you requesting Property Coverage?

Building Information

Year Renovated

Building Security

Fire Alarm
Burglar Alarm

General Liability

Are you requesting General Liability Coverage?
Are any autos used exclusively for business use?
Do any employees use a personal auto for business use?
Are any web based services offered?
Are credit card payments accepted?
Is there a program to identify identity theft?
Is there Underground Tank Leakage Exposure?
Is there a Pollution Exposure?

Professional Liability

Are you requesting Professional Liability Coverage?
Does your firm provide services outside the U.S.?
Does your firm use Independent Contractors (ICs) or Sub Contractors?
Does your firm provide services outside the U.S.?
Do you request Certificates of Insurance from ICs and Sub Contractors ?
Do you have written agreements on every project?
Are you requesting Medical Professional Liability Coverage?
Do you provide Professional Liability to your ICs and Sub Contractors?

Medical Professional Liability

Do ICs and Sub Contractors have written agreements?
Does your firm use Independent Contractors (ICs) or Sub Contractors?
Do you employ Physicians or Surgeons?
Is there a Medical Director?
Does the Medical Director have their own insurance?
Do you request Certificates of Insurance from ICs and Sub Contractors?
Do you have written agreements on every project?
Do ICs and Sub Contractors have written agreements?
Do you provide Professional Liability to your ICs and Sub Contractors?
Do you bill for Medicare/Medicaid?

Workers' Compensation

Are you requesting Workers’ Compensation Coverage?
Do you offer Paid Vacation?
Are Medical Benefits Offered?
Is there a formal Safety Program?

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