Business and Workers’ Compensation Insurance


* Name & DBA

* Business Address

* Telephone

*Email

Country

Member of an Association?

Who referred you?

Business Type (Sole Proprietor, Corp., Etc.)

Total Annual Sales

Number of Employees

Years in Business Management

Building Information


Business Personal Property/Contents Amount Needed (Including Tenant Improvements)

Do you own or lease your office space?
OwnLease

If owned, please list building limit:

Type of Building Construction (frame, brick, concrete, etc.)

Sprinklers in Building
YesNo

Alarm?
YesNo

If Yes, is alarm mentioned?
YesNo

Age of Building

Square Feet Occupied

If Building is over 20 years old, check the following updates:

 
Roof

 
Electric

 
Plumbing

 
Heating

Employee Information


Any claims in the last five years?
YesNo

Total Payroll

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)?
YesNo

Do you operate any other business other than chiropractic?
YesNo

Have there been any tax liens or bankruptcies in the last 5 years by you or your partner for this current or past business?
YesNo

Any claims in the past five years?
YesNo

Do you have your personal insurance through Warren G Bender Co.?
(If not, may we provide a free coverage and rate review?)
YesNo

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