Businessowners and Workers’ Compensation Insurance

Business personal property/contents amount needed(including tenant improvements):
Do you own or lease your office space?: Yes   No
If owned, please list building limit:
Type of building construction(frame, brick, concrete etc):
Sprinklers in Building: Yes   No		Alarm?: Yes   No
If Yes, is alarm mentioned?: Yes   No		Age of Building:
Sq. Ft Occupy:
If over 20 years old, list the following updates:
Roof	Electric	Plumbing	Heating
List any claims in the last five years?: Yes   No
Total Payroll:		Number of fulltime employees:
Number of Part time Employees:
What is your Federal Employer Identification Number(FEIN):
Expiration Date of WC Policy:

Any prior coverage cancelled or nonrenewed in last 3 years (other than for non-payment of premium): Yes   No
Do you operate any other business than chiropractic?: Yes   No
Have there been any tax lines or bankruptcies in the last 5 years by you or a partner for this current or a past business?: Yes   No
Any claims in the past five years: Yes   No
Do you have your personal insurance through Warren G. Bender Co.? (If not, may we provide a free coverage and rate review?): Yes   No
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