Current Insurance Information
Company Name (not agency):
Policy Expiration Date:	Premium Amount: $
NCCI Number:
NCCI Experience Modification Number:
What type of coverages do you currently have:
Bond Commercial Auto Commercial Liability Commercial Property Commercial Umbrella Directors & Officers Liability Disability Group Health Group Life Professional Liability Other

About Your Practice
# of full-time employees	# of part-time employees	How long in practice	How many locations	Estimated Annual Payroll
		years		$
Please give a brief description of your practice (below):

Additional Practice Information
Do you have any losses in the past 3 years?:	Yes No
Do you have Independent Contractors?:	Yes No
If yes, how many?:
Do paychecks reflect the above name?:	Yes No
If no, please provide details:
Federal Tax TD:
Type:	Corporation Partnership Individual    Other
Average hourly wage for non-physician employees:	$ / hour
List all Officers/Partners
Name: Title: % Ownership: Excluded/Included: Excluded Included Excluded Included Excluded Included Excluded Included Excluded Included Excluded Included
What is the practice specialty?
Off premise operations:	Yes No

Employee Information
Employee#	Classification code	Estimate Yearly Payroll
1
2
3
4
5
Please list additional employees in the "Additional Comments" section below

Additional Comments

Please give any additional comments you feel appropriate for this quotation. If you have additional information where there was not enough space, please enter them here.

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