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Chiropractic Protector Plan ÂŽ P.O. Box 173166 Tampa, FL 33672 Toll-Free: 844-239-1719 Fax: 813-222-4370 Email: info@cppinsurance.com Visit our Website: www.cppinsurance.com CA License No: 0G51291

WORKERS’ COMPENSATION QUESTIONNAIRE Requested Effective Date: Legal Business Name: Property Address: Mailing Address: Contact Phone: Legal Entity:

Email: Individual

Years of Experience:

Corporation

Partnership

Years in Business:

LLC

Other

Is this a new venture?

Amount of your gross sales: Location(s):

1. 2. 3.

How many total employees do you have?

What is your Federal Tax Id #: What is the gross salary for all employees, excluding Officers:

How many are part-time?

What is the gross salary for Officers?

Are Officers/Owners to be included or excluded?

List the names of all Officers/Owners: Any claims?

Name of current insurance Carrier:

If so, please attach a copy of the loss runs.

Have you been cancelled or nonrenwed? If so, please provide an explanation. : Are health benefits provided?

Out of state travel:

Salary for those doing grinding of lenses:

LIMITS:

Signature:

$100,000/$500,000/$100,000

Do employees dispose of hazardous materials? All other employees:

$500,000/$500,000/$500,000

Date:

$1,000,000/$1,000,000/$1,000,000


Workers Compensation Questionnaire - Chiropractic Insurance