Dental/Medical BOP Quote Form- Travis Sibley 2

Dental/Medical Professional 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
What's the name of the insurance carrier(s) your current Business Liability, Workers Compensation, and Business Umbrella are with?
Do you have declaration pages (policy summary pages) you can send us for these policies?

YESNO
Please send them to ServiceTeam@TheFirebirdAgency.com
When is the renewal date of these policies?

MonthDayYear
Date
Have you had any claims in the last 5 years? If yes, please explain
If using a DBA, what is the name of your practice (DBA)?
What's the legal name of your entity (meaning the legal name of you LLC, S-Corp, C-Corp, etc.)?*
How is this entity filed with the IRS? *
Start Month and Year of Practice Ownership?
Please provide your EIN number *
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)
Do you lease or own this property?
If you are 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 sprinkler system?

YesNoI'm not sure
How many water claims have you had in the last 3 years?
Please list addresses and names of each location (if applicable)
What are the Anticipated Gross Sales for the year?
How many employees do you have?
What is the Anticipated Annual Payroll for the year (not including your pay)?
Do you have more than one location?

YesNo
If you have more than one location, we will reach out to get similar information on those locations.
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.
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