Application For
Dentists

Personal Information:
Name:
Mailing Address:
Email Address:
Phone Number(s):
Business Information:
Practice Name:
Practice Mailing Address:
Practice Email Address:
Practice Phone Number(s):
Federal ID#:
Years in Business:
# of Employees:
Annual Payroll:
Annual Receipts:
# of Dentists: Payroll:
# of Hygeniests: Payroll:
# of Clerical: Payroll:
Are you the Tenant of the Building Owner:
Tenant  Building Owner
Building Coverage Amount (if Applicable):
Business Personal Property Amount:
Construction of Building: Check one
Frame
Joisted Masonry
Non-Combustible
Square Footage of the Building:
Describe other Building Occupants:
Square Footage Practice Occupies:
Original year building constructed:
Year of any updates:
Roof:
Electrical:
Plumbing:
Heating:
Does the building have any Alarm Systems:
Yes
No
CURRENT POLICY INFORMATION
Are you presently Insured?
Yes
No
Current Carrier:
Effective Date:
Current Annual Premium:
Have you had any claims in the past 3 years?
Yes
No
If Yes, Please describe:
Would you like a quote for:
(Please check coverage's requested)
Professional Liability
Workers' Compensation
Disability
Umbrella
Do you have any Auto's registered in the Business Name?
Yes
No
If yes, would you like a quote?
Yes
No
Year:
Make:
Model:
Comprehensive Deductible:
Collision Deductible: