Property and Worker’s Compensation Insurance

Please fill in all of the information below. A quote will be sent to you at the email address provided within 1 business day. Thank you for trusting The Doctors Insurance Broker.

Property and Worker's Compensation Quote

Name *
Business Name *
FEIN *
Address *
City, State *
Zip Code *
Phone Number
Fax Number
Email *
Date new coverage needs to be effective *
Tenant and Betterment Coverage (BLDG) $
Business Personal Property $
Legal Entity: *
CorporationLLCPartnershipIndividual
Practice Type: *
GeneralEndodontistOral SurgeryOrthodontistPedodontistPeriodontist
Number of Years in Business *
Number of Years at this Location *
Radio
Option 1Option 2Option 3
Building Year Built *
Square Footage of Building *
Leased *
Is there an alarm system? *
YesNo
Does the building contain automatic fire sprinklers? *
YesNo
The building construction is *
FrameMasonry
Year of Upgrades:
Roof *
Plumbing *
Electrical *
Heating *
Number of Employees:
Full Time *
FT Employee Annual Payroll *
Part Time *
PT Employee Annual Payroll *
Gross Sales *
Current Insurance Company
Policy Number
Expiration Date
Have you had any claims submitted to your insurance carrier in the last three years? *
YesNo
If Yes, please describe any losses in the last three years. Include date of loss, $ amount and details below.
Deductible (please choose one) *
$500$1,000$2,500Other
Other Deductible Amount
General Liability (please choose one) *
$1M$2M$3MOther
Other Liability Amount

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Property and Worker’s Compensation Insurance

Property and Worker's Compensation Quote

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