New Practice Purchase BOP Quote Form- Travis Sibley 2

New Practice Purchase Business Owners Policy (BOP) Quote Form
* Complete the following webform to obtain a business owner policy quote. If you don't know the answer to a question, simply state "I don't know". If the question does not apply, please put a "N/A" in the field. Thank you!
Which Team Member Referred You?
Full Name*

First NameLast Name
Cell Phone*
Please enter a valid phone number.
Email*
example@example.com
Date of Birth*

MonthDayYear
Date
Occupation*
Job Title/Specialty
When is the requested effective date of this policy?

MonthDayYear
Date
This is a(n):*

New/Start-up PracticeExisting Practice
Only complete the next few questoins if this purchase is an existing practice. if it's a start up practice, skip the next 2 questoins.
If this is an existing practice, what's the practice name?
Will you be changing the name of the practice?

YESNO
If using a DBA, what is the name of your practice (DBA)?
Have you set up a legal entity yet? (LLC, S-Corp, C-Corp, Sol Proprietorship)*

YESNO
What's the legal name of your entity (meaning the legal name of you LLC, S-Corp, C-Corp, etc.)? If you don't have one set up yet, please put your name here. *
How is this entity filed with the IRS?
Start Month and Year of Practice Ownership?
Please provide your EIN number
If you don't have a legal entity set up, we would be happy to refer you to one of our partners who will do it at a discounted cost.
What Year did the Practice Originate?
Practice Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
The Property address is:

A stand alone buildingAttached (strip mall/office condo)
Will you lease or own this property?
If you will be leasing, does your landlord require any specific business property limits? If so, please specify.
If you own the property, please answer the following 3 questions:
Do you have any high end equipment in the office? If so, please specify what it is and the approximate replacement cost of that equipment
Please list the name of entity that owns the building:
What's the value of building?
How many tenants do you have with your property?
Have any updates been done to your building/unit? If so, please advise what was done and the approximate year
What's the office square footage?
How many operations/exam rooms do you have?
What year was the building built?
Does the practice have an alarm system?

YesNoI'm not sure
Does this location have a fire sprinkler system?

YesNoI'm not sure
What are the Anticipated Gross Sales for the year?
How many employees do you/will you have?
What is the Anticipated Annual Payroll for the year?
Bank Loan Questions (If applicable)
Which bank are you securing your loan through?
When is the loan closing date?
How much is the total loan for this practice?
What are the bank's minimum business property limits needed to satisfy the loan requirements?
Consent and Authorization for Communication

To allow our agency the ability to provide your requested quote and to effectively schedule an appointment(s) to review that quote, we need to get your authorization to allow The Firebird Agency, LLC and our staff to communicate with you by means of emails, phone calls, and SMS text messages. By clicking the checkbox below and providing your email and phone number, you consent and agree to receive messages by those means from The Firebird Agency, its agents, and staff. Your authorization is allowing The Firebird Agency, their agents, and staff to also use SMS text messages to effectively communicate with you regarding our programs, offers, marketing, and other information that may be of interest to you. You also understand that you do not have to agree to receive autodialed or prerecorded calls or texts in order to use and enjoy the products and services offered by The Firebird Agency, LLC. You may decline to receive autodialed or prerecorded calls or texts to your mobile phone number in several ways, including by responding with STOP or by emailing the request to opt out with the mobile number, to serviceteam@fbagency.net Your carrier's standard messaging and data rates may apply. To move forward with working with our Firebird team, please give your authorization below. Then click the green submit button.
Should be Empty: