Chiropractic Protector Plan ÂŽ P.O. Box 173166 Tampa, FL 33672 Toll-Free: 844-239-1719 Fax: 813-222-4370 Email: email@example.com Visit our Website: www.cppinsurance.com CA License No: 0G51291
WORKERSâ€™ COMPENSATION QUESTIONNAIRE Requested Effective Date: Legal Business Name: Property Address: Mailing Address: Contact Phone: Legal Entity:
Years of Experience:
Years in Business:
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:
Do employees dispose of hazardous materials? All other employees: