Optometrists Businessowners and Professional Liability Quote

Professional Information
Name:
Address:
City:	State: Zip:
Day Phone:	County:
Fax:
Email Address:

Practice Information

Practice Name:		Type:
Current Professional Liability Insurer:		Renewal Date: (00/00/00):
# of Optometrists in Practice:		Number of Locations:
Have you had Professional Liability claims in the last 5 years?	yes no	( if yes, please explain)
Professional Liability Limits:		If other, Explanation:
Liability Policy Type:	Occurrence Claims Made	Retro Date (if Claims Made):
Premium (annual)

Would you like us to provide a quote for your office building and/or office contents?

If YES, Continue below

If NO, go to end of application.

Office Building Information

Rent or Own the Building?		Year Office Was Built:	(2000)
Is your building a Condo?	yes no	How Many Floors?:
Sq. Footage		Percent you occupy?:
Liability:		Miles to Fire Department:
Deductibles:		Feet to Hydrant:
Construction Type:		Sprinkler System
Replacement value of Business Personal Property (contents, equipment, furniture, inventory, etc.)		Near a body of Water
		Required to carry flood insurance?:
Current practice PROPERTY & BUSINESS LIABILITY carrier?		Premium $:
Renewal Date?:		Have you had property losses in the last 3 years?	yes no

If you own your building...

Current replacement Value?		Age of Bldg
Do you own the building under the same name as the Practice?	Yes No	if No, What name?

Umbrella Liability/ Worker's Comp

Current desired limits?		Number of officers
Annual payroll (excluding officers & owners)		Number of employees?

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.

Please click on the "Submit" button to send your quote request.

This is not an application for insurance and it does not obligate

this agency to issue any policy of insurance.

Website by Bradford WebMedia, Inc.

Optometrists Businessowners and Professional Liability Quote

Professional Information

If you own your building...

Umbrella Liability/ Worker's Comp

Additional Comments