Directors & Officers Insurance Short Form Questionnaire
State in which
you practice:
California
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:
Limits of
Liability:
per claim
annual aggregate
Deductible:
$10,000 per claim
$25,000 per claim
Other
Organization:
For-Profit Corp
Not-For-Profit Corp
Joint Venture
HMO
PPO
IPA
TPA
Other
Describe
Operations:
Annual Revenue:
Number of
Employees:
Years in
Business:
Receive your
quote by:
Telephone
E-Mail
Regular Mail
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.
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HealthCare Practice Group
A
Brown & Brown
, Inc. Company
Tel: (800) 435-6565- Fax: (714) 221-4129
E-Mail:
info@bbsocal.com
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