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

Workers' Compensation 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 ($5,000 annual minimum premium).

Name:

Address:

City:

Contact:

Telephone:

E-Mail:

Fax:

Effective Date:

Current Carrier:

Describe
Operations:

Do you provide Medical Benefits?

Yes No

Percentage Employer Pays:

Percentage of Employees Participating:

Is sick time provided?

Yes No

Is vacation time provided?

Yes No

Percentage of annual turnover?

Current number of full and part time employees and estimated annual payroll:

Job Classification	Full	Part	Payroll

How long have you been in business?

years

Have you had workers' compensation insurance coverage for three or more consecutive years?

Yes No

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