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PROFESSIONAL LIABILITY INSURANCE
Submitted by
insureitsmart
on Tue, 03/26/2019 - 00:09
1
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ABOUT YOU
Company Name
First Name
Last Name
Email
*
Street Address
City
State
- None -
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Marshall Islands
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
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Montana
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Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Marianas Islands
Ohio
Oklahoma
Oregon
Palau
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip
Phone(Day)
Phone(Evening)
Fax
ABOUT YOUR BUSINESS
Business Type
Sole Proprietor
Partnership
Corporation
LLC
Association
Do you currently have professional liability owners insurance?
*
Yes
No
If you answered 'yes' to having professional liability owners insurance
When does your current policy expire?
Month
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
Day
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31
Year
Year
2023
2024
2025
2026
2027
Who are you currently insured with?
Type of Business
Number of Owners or Officers
Description of Business Operations
Year Business Established
Month
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
Day
1
2
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30
31
Year
Year
1925
1926
1927
1928
1929
1930
1931
1932
1933
1934
1935
1936
1937
1938
1939
1940
1941
1942
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2002
2003
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2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
2025
Do you currently have business liability owners insurance?
Yes
No
Type of Insurance Desired
- None -
Errors and Omissions
Malpractice
Directors and Officers
Not Sure
Number of Locations
Number of Employees
Approximate Annual Gross Revenue
*
$
Approximate Amount of Desired Insurance
$
Has your company had claims in the last 3 years?
Yes
No
OPTIONAL COVERAGE
Check all that apply
Group Health
Business Property
Business Owners
Malpractice
Workers Compensation
Errors and Ommission
Commercial Auto/Truck
Other
Business Liability
Any Comments / Questions?
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