WMB Optometrist Questionnaire

Optometrist Questionnaire
General Information*

Named Insured - Legal name of the individual or entity to be listed on an insurance policy as the primary policyholder.

Street Address

CityState / Province

Postal / Zip Code
Primary Contact*

First NameLast NamePosition
Email Address*
example@example.com
Phone Number*
Please enter a valid phone number.
Location Information*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Number of Years Operating*
At the above listed location
Total Square Footage Occupied*
Of the above listed office
Total Number of Staff*
Working at the above listed location
Number of Optometrists on Staff*
Working at the above listed location
Current Policy Expiration Date*

MonthDayYear
Your office's current insurance policy expiry date
Sprinklered?*

YesNo
Premises Security - Alarmed?*

YesNo
Premises Security - If Alarmed:*

MonitoredLocal
Is the building over 25 years old?

OverUnder
Year Updated - Plumbing
The year of most recent updates
Details of Update - Plumbing
Year Updated - Electrical
The year of most recent updates
Details of Update - Electrical
Year Updated - Roof
The year of most recent updates
Details of Update - Roof

Values and Revenues
Value of Stock
Stock refers to the goods, merchandise, or materials such as eyeglasses, contact lenses, frames, and other optical products held for sale.
Value of Contents
Contents refer to the personal property or assets within a building, such as furniture, computers, and other items.
Value of Equipment
Equipment refers to the specialized tools and machinery used in eye care practices, such as diagnostic instruments, lens grinders, and optical testing devices.
Value of Tenants Improvements
Tenants' Improvements refer to modifications or enhancements made by a tenant to a rented property, such as built-in fixtures or custom designs.
Actual Revenue - Calendar Year 2024*
Actual Revenue refers to the total income generated by the optometry practice during the 2024 calendar year.
Projected Revenue - Calendar Year 2025*
Projected Revenue refers to the estimated future income the optometry practice expects to generate over the 2025 calendar year.
Construction Details
Year Built*
The year the building finished construction.
Number of Stories
The number of floors or levels to the building.
Replacement Cost of Building
Only required if you own the building.
Total Sqaure Footage Occupied*
Enter the square footage the optometry practice occupies.
Building Construction
Please refer to the Building Construction guide below.
Roof Construction
Please refer to the Roof Construction guide below.
Building Construction Guide:

Frame: Exterior walls of wood, brick veneer, stone veneer, wood ironclad, or stucco on wood (i.e. frame).

Non-combustible: Exterior walls, floor, and supports made of metal, asbestos, gypsum, or other noncombustible materials (i.e. concrete block, steel frame).

Fire resistive: Exterior walls, floors, and roof of masonry or fire-resistive materials with a fire resistance rating of at least 2 hours (i.e. poured concrete).
Roof Construction Guide:

Frame: joist/roof top.

Steel: 1) Frame joist with concrete.

2) Steel joist on Steel

Poured concrete: Concrete roof/top
Claims Disclosure
Select if you have had any insured losses in the past 5 years*

YesNo
If yes, please provide a description and details of the loss
Please provide details
Date of Loss

MonthDayYear
The specific calendar date when an insured event of damage occurred.
Amount Paid
Amount of monetary compensation issued by the insurer to the policyholder or beneficiary for an covered loss.
If yes, please provide a description and details of the loss
Please provide details
Date of Loss

MonthDayYear
The specific calendar date when an insured event of damage occurred.
Amount Paid
Amount of monetary compensation issued by the insurer to the policyholder or beneficiary for an covered loss.
Name

Applicant Full NameApplicant Position / Title
Signature

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Optometrist Questionnaire

Values and Revenues

Construction Details

Claims Disclosure