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:

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.

HealthCare Practice Group
A Brown & Brown, Inc. Company
Tel: (800) 435-6565- Fax: (714) 221-4129
E-Mail: info@bbsocal.com - Map: Location and Directions