HealthCare Professionals' Insurance Services : Medical Professional Liability Insurance : Medical Malpractice Insurance

Employment Related Practices Insurance Short Form Questionnaire

State in which
you practice:

If your state is missing, we are not licensed to broker this type of insurance in your state. If you have questions, please contact us at info@bbsocal.com or call (800) 435-6565

Name:

Address:

City:

Contact:

Telephone:

E-Mail:

Fax:

Effective Date:

Retroactive Date:

Current Carrier:

Describe
Operations:

Percentage of
annual turnover?

Indicate current number of persons serving as partners, directors and officers by salary range:

Partners	Directors	Officers	Salary Range
			$50,000 or less
			$50,001 - $100,000
			$100,001 - $200,000
			Over $200,000

Indicate current number of all other employees by salary range:

Managers	Sales	Full Time	Part Time	Salary Range
				$50,000 or less
				$50,001 - $100,000
				$100,001 - $200,000
				Over $200,000

Receive your
quote by:

Submit:

AUTHORIZED REPRESENTATIVE

Name:

Title:

By filling in my Name and Title above, I acknowledge that I am providing information that may be used to evaluate my application for an insurance policy and for other purposes set forth in the Privacy Statement and the Legal Notices found at the following links: http://www.bbinsurance.com/privacy.shtml and http://www.bbinsurance.com/legal.shtml. Further, by filling in my Name and Title above, I certify that I have read, understood and accepted each of the Privacy Statement and Legal Notices.

Must provide quotes in writing or via e-mail, not orally.

HealthCare Practice Group
A Division of Brown & Brown of California, Inc.
Tel: (800) 435-6565- Fax: (714) 221-4129
E-Mail: info@bbsocal.com - Map: Location and Directions