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:

Disclaimer: Our online application form are to provide current and prospective clients an indication of cost for various types of insurance policies they may wish to purchase. No coverage can be bound by this process. Hard copy, original signature, long form applications must first be obtained. Only after an insurance company has underwritten and provided written terms from this office can coverage be ordered.

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