Professional & Office Insurance Application
Covers Accounting Office Architect & Engineer Medical Office Mortgage Brokers Real Estate Office
Business Name, DBA (Doing Business As)
Address
Street Address
City
State
Zip Code
Contact person
E-mail
Phone Number
-
Area Code
Phone Number
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Which proposals can we send you?
Business Property (Office Contents & Equipment)
Cyber Liability
Employment Practices Liability (EPLI)
General Liability
Umbrella Liability
Workers’ Compensation
Accounting Office
Architect & Engineer
Medical Office
Mortgage Brokers
Real Estate Office
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Business Operations
Rows
Dollar Amount
What are your total gross revenues for the past 12 months?
$-
$5,000
$10,000
$25,000
$50,000
$100,000
$150,000
$250,000
$300,000
$400,000
$500,000
$600,000
$750,000
$1,000,000
$1,500,000
$2,000,000
$2,500,000
Average number of patients/clients per week (if medical or veterinary):
Under 50
51–100
101–250
Over 250
Do you perform any services outside the office (house calls, mobile PT, mobile vet, home closings)?
Yes – Regularly
Yes – Occasionally
No
Do you store or handle sensitive client/patient data (medical records, financial info, real estate contracts)?
Yes – Electronic Records Only
Yes – Paper & Electronic Records
No
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Rows
Coverage options
What is the estimated replacement cost value of office contents and equipment?
$-
$25,000
$50,000
$100,000
$150,000
$200,000
$250,000
$300,000
$350,000
$400,000
$450,000
$500,000
$550,000
$600,000
$650,000
$700,000
$750,000
$800,000
$850,000
$900,000
$950,000
$1,000,000
$1,250,000
$1,500,000
$1,750,000
$2,000,000
$2,250,000
$2,500,000
What is the estimated value of electronic equipment and computer systems used in your office?
$-
$25,000
$50,000
$100,000
$150,000
$200,000
$250,000
$300,000
$350,000
$400,000
$450,000
$500,000
$550,000
$600,000
$650,000
$700,000
$750,000
$800,000
$850,000
$900,000
$950,000
$1,000,000
$1,250,000
$1,500,000
$1,750,000
$2,000,000
$2,250,000
$2,500,000
What is the estimated value of tenant improvements or office build-out?
$-
$25,000
$50,000
$100,000
$150,000
$200,000
$250,000
$300,000
$350,000
$400,000
$450,000
$500,000
$550,000
$600,000
$650,000
$700,000
$750,000
$800,000
$850,000
$900,000
$950,000
$1,000,000
$1,250,000
$1,500,000
$1,750,000
$2,000,000
$2,250,000
$2,500,000
Do you own or lease your office space?
Own
Lease
What is the building construction type?
Frame
Joisted Masonry
Non-Combustible
Masonry Non-Combustible
Modified Fire-Resistive
Fire-Resistive
Do you have a central station alarm system?
Yes – Burglar & Fire
Yes – Burglar Only
Yes – Fire Only
No
Do you have a sprinkler system?
Yes – Full Building
Yes – Partial Area
No
Approximate office size:
Under 1,000 sq. ft.
1,001–2,500 sq. ft.
2,501–5,000 sq. ft.
Over 5,000 sq. ft.
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Rows
Annual Payroll
What is the estimated annual payroll for owners, partners, or corporate officers?
$-
$25,000
$50,000
$100,000
$150,000
$200,000
$250,000
$300,000
$350,000
$400,000
$450,000
$500,000
$550,000
$600,000
$650,000
$700,000
$750,000
$800,000
$850,000
$900,000
$950,000
$1,000,000
$1,250,000
$1,500,000
$1,750,000
$2,000,000
$2,250,000
$2,500,000
What is your estimated annual payroll for clerical and office employees?
$-
$25,000
$50,000
$100,000
$150,000
$200,000
$250,000
$300,000
$350,000
$400,000
$450,000
$500,000
$550,000
$600,000
$650,000
$700,000
$750,000
$800,000
$850,000
$900,000
$950,000
$1,000,000
$1,250,000
$1,500,000
$1,750,000
$2,000,000
$2,250,000
$2,500,000
How many employees do you have?
0 (Owner Only)
1–5
6–10
11–20
20+
Rows
Federal ID
What is the EIN Number?
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