* Name & DBA
* Business Address
Member of an Association?
Who referred you?
Business Type (Sole Proprietor, Corp., Etc.)
Total Annual Sales
Number of Employees
Years in Business Management
Business Personal Property/Contents Amount Needed (Including Tenant Improvements)
Do you own or lease your office space?
If owned, please list building limit:
Type of Building Construction (frame, brick, concrete, etc.)
Sprinklers in Building
If Yes, is alarm mentioned?
Age of Building
Square Feet Occupied
Any claims in the last five years?
Number of full time employees
Number of part time employees
What is your Federal Employer Identification Number (FEIN)?
Expiration Date of WC Policy
Any prior coverage cancelled or non-renewed in the last 3 years (Other than for non-payment of premium)?
Do you operate any other business other than chiropractic?
Have there been any tax liens or bankruptcies in the last 5 years by you or your partner for this current or past business?
Any claims in the past five years?
Do you have your personal insurance through Warren G Bender Co.? (If not, may we provide a free coverage and rate review?)
Please Enter the Security Code Below:
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