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Chiropractic Protector Plan ® 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

OFFICE PACKAGE AND WORKERS’ COMPENSATION QUESTIONNAIRE Legal Business Name: Property Address: Mailing Address: Contact Phone:

Email:

Legal Entity:

Individual

Years of Experience: Interest Type:

Corporation

Partnership

Years in Business: Owner Occupied

Tenant

Lessor

Amount of your gross sales:

Requested Effective Date:

If yes, does the Condo Assn cover the building?

Replacement Value Contents:

Building Value: Construction: (check one)

Fire Sprinkler System?

# of Stories: Central Station Alarm?

If yes, do you own the unit?

Replacement Value Build-Out:

Frame walls and wood roof Poured concrete with steel beam roof

Date of Original Construction:

Other

Is this a new venture?

PROPERTY INFORMATION – LOC 1 Is this a Condo Unit?

LLC

Concrete block with wood beam roof Concrete block with steel beam roof

Total Square Footage: Monitored by?

Sq Foot Occupied: Distance to Fire Hydrant:

Year Updated: Plumbing:

Roof:

Electric:

A/C:

Name of Current Insurance Carrier:

Renovations underway/anticipated: Prior carrier policy number, if known:

Have you been cancelled or non-renewed? If so, please please provide an explanation. :

Any Claims in last 5 years:

If yes, briefly describe:

Please attach the names and addresses of any Mortgagees, Loss Payees, Additional Insured’s, or Certificate Holders to be incl uded.

Page 1


PROPERTY INFORMATION – LOC 2 Is this a Condo Unit?

Requested Effective Date:

If yes, does the Condo Assn cover the building?

Replacement Value Contents:

Building Value: Construction: (check one)

Fire Sprinkler System?

Replacement Value Build-Out:

Frame walls and wood roof Poured concrete with steel beam roof

Date of Original Construction:

# of Stories: Central Station Alarm?

If yes, do you own the unit?

Concrete block with wood beam roof Concrete block with steel beam roof

Total Square Footage:

Sq Foot Occupied:

Monitored by?

Distance to Fire Hydrant:

Year Updated: Plumbing:

Roof:

Electric:

A/C:

Renovations underway/anticipated:

Name of Current Insurance Carrier:

Prior carrier policy number, if known:

Have you been cancelled or non-renewed? If so, please please provide an explanation. :

Any Claims in last 5 years:

If yes, briefly describe:

PROPERTY INFORMATION – LOC 3 Is this a Condo Unit?

Requested Effective Date:

If yes, does the Condo Assn cover the building?

Replacement Value Contents:

Building Value: Construction: (check one)

Fire Sprinkler System?

Replacement Value Build-Out:

Frame walls and wood roof Poured concrete with steel beam roof

Date of Original Construction:

# of Stories: Central Station Alarm?

If yes, do you own the unit?

Concrete block with wood beam roof Concrete block with steel beam roof

Total Square Footage: Monitored by?

Sq Foot Occupied: Distance to Fire Hydrant:

Year Updated: Plumbing:

Roof:

Electric:

A/C:

Name of Current Insurance Carrier:

Renovations underway/anticipated: Prior carrier policy number, if known:

Have you been cancelled or non-renewed? If so, please please provide an explanation. :

Any Claims in last 5 years:

If yes, briefly describe: Page 2


PROPERTY INFORMATION – LOC 4 Is this a Condo Unit?

Requested Effective Date:

If yes, does the Condo Assn cover the building?

Replacement Value Contents:

Building Value: Construction: (check one)

Fire Sprinkler System?

Replacement Value Build-Out:

Frame walls and wood roof Poured concrete with steel beam roof

Date of Original Construction:

# of Stories: Central Station Alarm?

If yes, do you own the unit?

Concrete block with wood beam roof Concrete block with steel beam roof

Total Square Footage:

Sq Foot Occupied:

Monitored by?

Distance to Fire Hydrant:

Year Updated: Plumbing:

Roof:

Electric:

A/C:

Renovations underway/anticipated:

Name of Current Insurance Carrier:

Prior carrier policy number, if known:

Have you been cancelled or non-renewed? If so, please please provide an explanation. :

Any Claims in last 5 years:

If yes, briefly describe:

PROPERTY INFORMATION – LOC 5 Is this a Condo Unit?

Requested Effective Date:

If yes, does the Condo Assn cover the building?

Replacement Value Contents:

Building Value: Construction: (check one)

Fire Sprinkler System?

Replacement Value Build-Out:

Frame walls and wood roof Poured concrete with steel beam roof

Date of Original Construction:

# of Stories: Central Station Alarm?

If yes, do you own the unit?

Concrete block with wood beam roof Concrete block with steel beam roof

Total Square Footage: Monitored by?

Sq Foot Occupied: Distance to Fire Hydrant:

Year Updated: Plumbing:

Roof:

Electric:

A/C:

Name of Current Insurance Carrier:

Renovations underway/anticipated: Prior carrier policy number, if known:

Have you been cancelled or non-renewed? If so, please please provide an explanation. :

Any Claims in last 5 years:

If yes, briefly describe:

Page 3


WORKERS’ COMPENSATION INFORMATION Requested Effective Date: 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:

Are health benefits provided?

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

Out of state travel:

Salary for those doing grinding of lenses:

LIMITS:

Do employees dispose of hazardous materials?

All other employees:

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

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

UMBRELLA INFORMATION UMBRELLA LIMITS:

Notes:

$1,000,000

$2,000,000

$3,000,000

Other

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


Office Package and Workers Compensation Questionnaire - Chiropractic Insurance