Physicians Insurance
1-800-962-1399 Create Account
  
SHARE:  

Disability Business Overhead Expense - Questionnaire


Please complete the form below.

(* indicates a required field)

Contact name: *
Clinic Name:  
 
Incorporated?    Yes
 No
 
Phone: *
Fax:  
E-Mail: *
 
Address: *
City: *
State: *
Zip code: *
 
Current Overhead Expense Insurance Coverage

Monthly overhead (not including physician's income): *
 
Elimination period (days):    30
 60
 90
 180
 
Benefit period:    12 months
 15 months
 24 months
 
Supplemental Benefits

 Future income option
 Residual (Partial)
 
Comments:

 

(206) 343-7300 | 1-800-962-1399 | Fax: (206) 343-7100 | E-mail Us
Your Account | Contact Us | Privacy & Terms of Use
Stay Current, Stay Connected: WordPress Blog  Facebook  Twitter  LinkedIn