Home
Mission Statement
Pressroom
Commercial Lines
Personal Lines
Bonds
Employee Benefit Services
Broker Services
Service Support
Human Resource Services
Access to Markets
Senior Living Insurance Program
Construction
Electrical Contractor's Insurance
Public Entities
Canadian Co’s in the US
Energy Insurance
Risk Management
Carriers Represented
Property & Casualty Insurance
Employment Opportunities
Contact Us

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#:
U/E#:
# 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:
Does the building have any Alarm Systems:
Yes
No
CURRENT POLICY INFORMATION
Are you presently Insured?
Yes
No
Current Carrier:
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
Do you have any Auto's registered in the Business Name?
Yes
No
If yes, can we provide you with a Commercial Auto quote?
Yes
Year:
Make:
Model:

 
     
   

 

  

About Us | Represented Companies | Mission Statement | Insurance Resources | Contact Us | Site Map

Small Business Insurance - Cool Insuring Agency, Inc. • 784 Troy-Schenectady Rd • Latham, NY 12110 • 800 233-0115

Website Design, Development and Search Engine Optimization by Mannix Marketing, Inc.