1. Named
Insured and mailing address: ___________________________________________
_______________________________________________________________________
_______________________________________________________________________
Legal Entity: qIndividual qCorporation qPartnership Other: _______
2. Effective date of coverages:
3. Liability Limit - $1,000,000 standard: _______________________________________
4. Umbrella requested? q$1 mil q$2 mil q$3 mil q$4 mil q$5 mil5. Address for each location:
Loc 1 ______________________________ Loc 4 _________________________________
Loc 2 ______________________________ Loc 5 _________________________________
Loc 3 ______________________________ Loc 6 _________________________________
5.b. PROPERTY SUMMARY - what would it cost to replace with like kind and quality today?
Locations |
Leasehold Improvements |
Office Furniture |
Computers On Site/Off |
Medical Diagnostic Equipment |
Valuable Papers |
| 1. | |||||
| 2. | |||||
| 3. | |||||
| 4. | |||||
| 5. | |||||
| 6. |
5c. Employee Dishonesty - $15,000 incl. Increase by: q$5,000 q$10,000 q$25,000 q$50,000
KEY
|
VALUABLE PAPERS (Patient's
Charts) - cost to replace charts. |
|
IMPROVEMENTS AND BETTERMENTS -
Practice's investment in setting up the office to their specifications, i.e. partitioning,
wall coverings. |
|
FURNITURE & FIXTURES -
Examining rooms, waiting rooms, cabinets, files, photocopier, fax, phones. |
|
COMPUTERS - break out cost of
hardware and software by location. |
|
MEDICAL DIAGNOSTIC EQUIPMENT -
Any medical diagnostic equipment controlled by a computer chip, i.e. ECHO, nuclear camera,
EKG. |
L O C A T I O N 1
6.
What are the other occupancies in the building at location 1?
________________________________________________________________________
________________________________________________________________________
7. Approximate square footage of your office and of the entire building in location 1.
office: __________________ sq. ft. entire bldg: __________________ sq. ft.
8. Building: Age _________ years Replacement Cost q ACV q
Construction:
q Frame (exterior walls are wood or combined with other combustible materials such as brick veneer, stone veneer, wood ironclad or stucco on wood)
q Masonry (exterior walls are masonry materials such as adobe, brick, concrete, stone, tile and floors/roof are combustible)
q Fire Resistive (exterior walls, floors and roof are masonry or other fire resistive materials)
9. Is the whole building sprinklered? q Yes q No
10. What protective devices does this location have?
q Watchman q Premises Burglary Alarm q Perimeter Lighting
q Automatic Fire Alarm
q External Gong Alarm
L O C A T I ON 2
6.
What are the other occupancies in the building at location 2?
_________________________________________________________________________
_________________________________________________________________________
7. Approximate square footage of your office and of the entire building in location 1.
office: __________________ sq. ft. entire bldg: __________________ sq. ft.
8. Building: Age _________ years Replacement Cost q ACV q
Construction:
q Frame (exterior walls are wood or combined with other combustible materials such as brick veneer, stone veneer, wood ironclad or stucco on wood)
q Masonry (exterior walls are masonry materials such as adobe, brick, concrete, stone, tile and floors/roof are combustible)
q Fire Resistive (exterior walls, floors and roof are masonry or other fire resistive materials)
9. Is the whole building sprinklered? q Yes q No
10. What protective devices does this location have?
q Watchman q Premises Burglary Alarm q Perimeter Lighting
q Automatic Fire Alarm q External Gong Alarm
11. Deductible: q $500 q $1,000 q $5,000
12. Are you a condo unit owner? q Yes q No
If "Yes" - Do you need Loss Assessment Coverage? q Yes q No
13. If you are a tenant, who is the landlord and do they need to be added as an additional insured?
- landlord's name and address: ___________________________________________________________________________
___________________________________________________________________________
- add as an additional insured? q Yes q No
13b. Name and address of all Loss
Payees and Additional Insureds:
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
14. Number of part-time and full-time employees: PT _______ FT ______
14b. Estimated payroll of
corporation with the stockholder/officers $ ____________________________
maxed out at
$72,000 each:
14c. List of corporate officers:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
14d. What is your Federal Identification number? ___________________________________________
What is your New Jersey Employers Registration number? _________________________________
(also
known as your unemployment number)
14e. Are there any health plans available to employees? qYes q No
15. Have you had any
claims in the last 5 years?
q Yes - A detailed description is
needed.
16. Who is your
professional liability carrier?
________________________________________________________________________________
17. Who is your Medical
Waste Disposal Contractor?
________________________________________________________________________________
P R E V I O U S I N S U R A N C E
LINE OF BUSINESS EFFECTIVE DATE LINE OF BUSINESS EFFECTIVE DATE
Businessowners - - - Umbrella - - -
Professional - - Workers' Comp. - -
S U P P L E M E N T A L L O C A T I O N S
L O C A T I O N 3
6. What
are the other occupancies in the building at location 3?
__________________________________________________________________________
__________________________________________________________________________
7. Approximate square footage of your office and of the entire building in location 1.
office: __________________ sq. ft. entire bldg: __________________ sq. ft.
8. Building: Age ______ years Replacement Cost q ACV q
Construction:
q Frame (exterior walls are wood or combined with other combustible materials such as brick veneer, stone veneer, wood ironclad or stucco on wood)
q Masonry (exterior walls are masonry materials such as adobe, brick, concrete, stone, tile and floors/roof are combustible)
q Fire Resistive (exterior walls, floors and roof are masonry or other fire resistive materials)
9. Is the whole building sprinklered? q Yes q No
10. What protective devices does this location have?
q Watchman q Premises Burglary Alarm q Perimeter Lighting
q Automatic Fire Alarm q External Gong Alarm
L O C A T I O N 4
6.
What are the other occupancies in the building at location 4?
__________________________________________________________________________
__________________________________________________________________________
7. Approximate square footage of your office and of the entire building in location 1.
office: __________________ sq. ft. entire bldg: __________________ sq. ft.
Building: Age _________ years Replacement Cost q ACV q
Construction:
q Frame (exterior walls are wood or combined with other combustible materials such as brick veneer, stone veneer, wood ironclad or stucco on wood)
q Masonry (exterior walls are masonry materials such as adobe, brick, concrete, stone, tile and floors/roof are combustible)
q Fire Resistive (exterior walls, floors and roof are masonry or other fire resistive materials)
9. Is the whole building sprinklered? q Yes q No
10. What protective devices does this location have?
q Watchman qPremises Burglary Alarm q Perimeter Lighting
q Automatic Fire Alarm q External Gong Alarm
L O C A T I O N 5
6. What are the other
occupancies in the building at location 5?
____________________________________________________________________________
____________________________________________________________________________
7. Approximate square footage of your office and of the entire building in location 1.
office: __________________ sq. ft. entire bldg: __________________ sq. ft.
Building: Age _________ years Replacement Cost q ACV q
Construction:
q Frame (exterior walls are wood or combined with other combustible materials such as brick veneer, stone veneer, wood ironclad or stucco on wood)
qMasonry (exterior walls are masonry materials such as adobe, brick, concrete, stone, tile and floors/roof are combustible)
q Fire Resistive (exterior walls, floors and roof are masonry or other fire resistive materials)
9. Is the whole building sprinklered? q Yes q No
10. What protective devices does this location have?
q Watchman q Premises Burglary Alarm q Perimeter Lighting
q Automatic Fire Alarm q External Gong Alarm
L O C A T I O N 6
6.
What are the other occupancies in the building at location 6?
__________________________________________________________________________
__________________________________________________________________________
7. Approximate square footage of your office and of the entire building in location 1.
office: __________________ sq. ft. entire bldg: __________________ sq. ft.
8. Building: Age _________ years Replacement Cost q ACV q
Construction:
q Frame (exterior walls are wood or combined with other combustible materials such as brick veneer, stone veneer, wood ironclad or stucco on wood)
qMasonry (exterior walls are masonry materials such as adobe, brick, concrete, stone, tile and floors/roof are combustible)
q Fire Resistive (exterior walls, floors and roof are masonry or other fire resistive materials)
9. Is the whole building sprinklered? q Yes q No
10. What protective devices does this location have?
q Watchman q Premises Burglary Alarm q Perimeter Lighting
q Automatic Fire Alarm q External Gong Alarm