Physicians Insurance
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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: *
Location address: *
City: *
State: *
Zip code: *

Mailing address
(if other than principal office):
 
City:  
State:  
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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