Optometrist Questionnaire
General Information
*
Named Insured - Legal name of the individual or entity to be listed on an insurance policy as the primary policyholder.
Office Location Address
City
State / Province
Postal / Zip Code
Optometry Practice Details
Value of Contents
Contents refer to the personal property or assets within a building, such as furniture, equipment, stock, computers, and other items.
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.
Projected Revenue 2025
Revenue refers to the total income generated by the optometry practice during the calendar year.
Year Built
The year the building finished construction.
Building Construction
Please Select
Frame
Concrete
Please refer to the Building Construction guide below.
Claims Disclosure
Select if you have had any insured losses in the past 5 years
*
Yes
No
If yes, please provide a description and details of the loss
Please provide details
Date of Loss
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
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 Name
Applicant Position / Title
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Current Policy Documents
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Submit
Should be Empty: