Premium Indication Request

Business Owners Policy (available to current Physicians Insurance policyholders only)

Offered through Physicians Insurance Agency

(* indicates a required field)

Physicians Insurance policy number:	*
Physician or entity name:	*
Business type:	*	Individual Partnership Corporation
Location address:	*
City:	*
State:	*	Idaho Oregon Washington
Zip code:	*
Mailing address (if other than principal office):
City:
State:		Idaho Oregon Washington
Zip code:
Preferred contact phone number:	*
Fax:
E-Mail:
If owned by you, replacement cost of the building?		$
Any business insurance losses (last 3 years):	*	Yes  No
Requested effective date:	*
Do you have a present carrier?	*	Yes  No
If yes, which carrier?
Desired property deductible:	*	$500  $1000
BUILDING INFORMATION
Check which best describes the building's construction: *
Wood frame with stucco covering the exterior  Brick or other masonry/cinder blocks - wood floors  Masonry with cement floors  Steel/concrete and glass
Year building was built (approx):	*
Office sq. ft.:	*
Dates of last roof and electrical updates (if over 25 years old):	*
Is the building sprinklered:	*	Yes  No
CONTENTS COVERAGE AMOUNT
Desired coverage limit for your office contents:	*	$
(Incl. furniture, fixtures, owned, rented or leased equipment, betterments and improvements)

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