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What Does your Business
Do? |
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Federal Employer
Identification Number |
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Years in Business |
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Current Ins Carrier |
2008-Insurance Company
Name
Policy Number Expiration
Date How many years have you
been with them?
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Current Ins Carrier-(If
you have not carried professional liability coverage for the last three
years we need a resume of all the owners) |
2007-Professional
Liability Insurance Company
Name
Policy Number Expiration
Date How many years have you
been with them?
Claims Made Date "Retroactive Date"
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| |
2006-Professional
Liability Insurance Company
Name
Policy Number Expiration
Date How many years have you
been with them?
Claims Made Date "Retroactive Date"
|
| |
2005-Professional
Liability Insurance Company
Name
Policy Number Expiration
Date How many years have you
been with them?
Claims Made Date "Retroactive Date"
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| Hours Of Operation |
OpenClosed |
| Do you sub-contract any work
out to others? How Much %? |
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| Years Experience in this type
of business |
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| Sales or Receipts(Annually) for
the last three years |
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Do you own any
other company? |
If yes please describe Below
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| Requested
Liability Liability Limit |
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| What
deductible would you like us to quote for? |
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Has any Errors and Omissions insurance ever been declined, or has
any such insurance ever been cancelled in the past three years?
can |
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| Are you
engaged in any other profession or business?
If yes explain. |
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| Have any
claims, suits or proceeding been made during the past five years against any
of you or your firm, your predecessors in business or against any present
partners, owner, officers or employees? |
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| Are ay of you
aware of any alleged act,circumstance, situation, error or omission whch may
result in a claim being made against you or any of the persons or firms
described? |
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