BUSINESSOWNERS APPLICATION

Transcription

1 Dentists Benefits Insurance Company Northwest Dentists Insurance Company BUSINESSOWNERS APPLICATION GENERAL INFORMATION 1. Named insured: 2. Requested effective date: Referred by: 3. Office address: Street City State Zip County 4. Name of your legal entity (if any): 5. Include any dba s: 6. If you have a legal entity, do you want it included on this policy? Yes No 7. Telephone Number: ( ) Fax Number: ( ) 8. Cell Phone Number: ( ) 9. Mailing Address: Street City State Zip 10. Preferred Contact Method: Office Cell Other: 11. Number of full time employees: Number of part time employees: Do you have any leased employees? Yes No Do you have any independent contractors? Yes No 12. List any other business with which you or any family members have any financial interest: Preferred billing plan: Annual Semi-annual* Quarterly* Monthly EFT only (subject to availability) *installment fees apply BOP APP (07/2015) [1]

2 GENERAL LIABILTY COVERAGE 13. Requested Limits: $1,000,000 per claim / $2,000,000 aggregate $2,000,000 per claim / $4,000,000 aggregate Other 14. If you lease your space, please provide name and address of building owner or landlord/property manager: Building Owner or Landlord/Property Manager Street City State Zip Please attach a copy of your lease agreement and a current photo of the building including one operatory. DENTAL LABORATORY/DENTAL IMAGING SERVICES 15. Do you have Cone Beam imaging equipment in your office? Yes No 16. If yes, do you perform imaging services for others? Yes No 17. Do you own any other commercial property? Yes No If yes, type of property: PROPERTY COVERAGE Coverage Limits Requested: 18. Building Replacement Value (if applicable): $ 19. Business Personal Property (replacement value of contents, computers, equip, etc): $ Please break down the values of the following (included in your limit above): Total value of tenant improvements: $ Total value of computer equipment: $ Are computers networked? Yes No Value of Dental Equipment: $ Total number of operatories: 20. Is your office located in a condominium? Yes No If yes, do you own the Condominium? Yes No 21. Do you have signs? Yes No Are the signs attached to the building: Yes No Please provide value of signs: $ 22. Property Deductible: $500 $1,000 $2,500 $5,000 Other: 23. Mortgagee or Loss payee (Bank, Finance Company, etc.): Mailing Address: Street City State Zip Loan # BOP APP (07/2015) [2]

3 24. Building Owner or Property Manager: Address: If you own your building: Do you have tenants? Yes No Do you require proof of general liability insurance from your tenants? Yes No Are they required to list you as an additional insured? Yes No Type of business operated by other building tenants: 25. Your gross annual revenue: $ Gross annual rental receipts (if any) $ 26. Your estimated Annual Payroll: $ 27. Total amount of prescription drugs onsite: $ Please list types: 28. Total amount of precious metals on site: $ PROPERTY INFORMATION All information must be completed 29. Year Built: If building is older than 25 years old, please provide the year the following updates were completed: Wiring Roof Plumbing Heating/Air Conditioning 30. Miles from fire station: Feet from hydrant: 31. Building construction type: Frame Masonry Brick Veneer Reinforced Concrete Frame Pre-Engineered Metal Frame Other: 32. Roof construction is: Age of roof: Floor construction is: 33. Number of stories: What floor is your office located? 34. Total square footage of your office: Building square footage: 35. Alarms: Fire Burglar Combined fire/burglar Local Central 36. Is the building equipped with a sprinkler system? Yes No 37. Solenoid switch (automatic water shut-off valve): Yes No 38. If yes, is the system activated when practice is closed: Yes No CRIME Please complete all information 38. How do your store: Prescription drugs Safe/vault Locked cabinet Cash on hand Safe/vault Locked cabinet Precious metals Safe/vault Locked cabinet Other (please describe): BOP APP (07/2015) [3]

4 39. Who has keys or has access to your building after hours? 40. What is their present position within your office? 41. Is there a CPA audit at least once a year? Yes No 42. Who has authority to sign checks in your practice? Name: Position: Name: Position: 43. Is there a monthly reconciliation of all accounts by a person who does not prepare and make deposits? Yes No 44. Who is primarily responsible for the oversight of financial issues in your office? Office staff Professional accountant or bookkeeper Family member Myself Office manager Name: OTHER COVERAGE Please indicate limits desired Accounts receivable: ($25,000 included) Employee dishonesty: ($25,000 included) Valuable papers: ($10,000 included) Welfare & Pension Plan: ($25,000 included) CLAIM HISTORY List all losses during the last five years (please provide a current five-year loss history including the current year): Date of occurrence Amount paid Description of loss Are there circumstances of which you are aware that might give rise to a claim or suit even if you believe the possibility of a claim or suit would be without merit? Yes No If yes, please provide details in remarks section. Any policy or coverage declined, cancelled or non-renewed? Yes No If yes, please provide details in remarks section. Current insurer: Expiration date: BOP APP (07/2015) [4]

5 I understand that this application does not bind or guarantee issuance of property or general liability insurance coverage. I certify that as of the date of my signature below, I am not aware of any events, incidents or circumstances which I might expect to result in any type of claim or suit to be filed or asserted against me in any manner, except those specifically disclosed in this application for insurance. I acknowledge that as a condition precedent to acceptance of this application and any future renewal thereof, an inquiry and investigation of my professional background, qualification and competence, including such other underwriting or claim matters as are deemed relevant, may be conducted by us or our duly authorized representatives. I expressly consent to any such inquiry and investigation and hereby authorize the release and exchange of information pertaining to such inquiry and investigation. Submitted by: Signature Name and title (please print) Date Telephone number FRAUD NOTICE WHERE APPLICABLE UNDER THE LAW OF YOUR STATE Any person who knowingly and with intent to defraud or solicit another to defraud an insurer (1) by submitting an application, or (2) by filing a claim containing a false statement as to any material fact, may be violating state law and may be subject to prosecution for insurance fraud. FRAUD STATEMENT TO ARIZONA APPLICANTS Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. FRAUD STATEMENT TO IDAHO, TENESSEE AND WASHINGTON APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits. COMPLETION OF THIS FORM NEITHER BINDS COVERAGE NOR GUARANTEES A POLICY WILL BE ISSUED. Signature Date BOP APP (07/2015) [5]

6 ARE YOU INTERESTED IN RECEIVING A QUOTE ON ANY OF THE FOLLOWING? Earthquake: Yes No Flood: Yes No Employment Practices Liability: Yes No Cyber Security: Yes No Workers Compensation: Yes No ERISA Yes No REMARKS: 601 SW Second Ave, Portland, Oregon Phone: DBIC NORDIC Fax: Websites: dentistsbenefits.com BOP APP (07/2015) [6]