Contact Name
Last Name
First Name
Business Name
DBA
Is this a non-profit organization?
Is 25% of this company owned by a private equity fund structure?
Check the appropriate box for federal tax classification of the entity?
Business Address
Tele Phone
-
Area Code
Tel. Number
Fax
-
Area Code
Fax Number
Website
Email
example@example.com
Federal Employer Tax ID Number
*
Format: 00-0000000.
NPI
*
Year Established
Desired Policy Effective Date
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Current Coverage Expration date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Current Insurance carrier
*
Have you had any claims or losses in the past 3 years?
*
Yes
No
# of years under current Management
Last year Total Revenue
# of clients/Patients Served last year
Total Number of W2 Employees
# Independent Contractor in 12 months
Do you want independent contractors to be included in the coverage?
Is the Applicant accredited or a member of the following health care organizations:
Line of Business your organization need the coverage for: (Select Multiple if needed)
Do you provide Service to/in the:
Nursing Home
Skilled Nursing Facility
Assited Living Facilty
Correctional Facilty
Total number of employees in your agency on W2
*
Total number of employees in your agency on Contract
*
Is the Applicant Licensed to Do Business in the States In Which They Do Business?
Select all the coverages you are requesting a quote for your agency:
Please Provide the name of a business entity or third party that you want to extend coverage to as an Additional Insured?
Has the entity, any applicant requesting coverage, or any employees ever been: Charged with, convicted of, or indicted for any act committed in violation of any law or ordinance, other than traffic offenses, or have ever had hospital privileges, DEA license, healthcare license or reimbursement privileges denied, refused, revoked, suspended, restricted, subject to a reprimand, placed on probation, or voluntarily surrendered? Accused of sexual misconduct of any kind? Are aware of a health condition that could impair the ability to practice their profession? (Including addiction to alcohol, narcotics or other controlled substances.)
Yes
No
Has the entity, any applicant requesting coverage or any employees ever had any insurance company ever cancel, decline, non-renew, or rescind a prior insurance policy?
Yes
No
Has the entity, any applicant requiring coverage or any employees ever been:HelpInvolved in a claim; e.g., a demand for money;Involved in a lawsuit; and/orAware of any complication, event, incident or adverse outcome that might reasonably result in a claim or lawsuit against you?
Yes
No
NAME OF AUTHORIZED SIGNATORY
TITLE
DATE
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Please verify that you are human
*
Submit
Should be Empty: