Professional Liability Insurance Form

Please complete as much of this form as possible.

Business Information
Business Name*	A value is required.
Type of Business (For Example, Consultant, Medical, Real Estate, Law Practice, etc.)
Years in Business

Business Contact Information
Contact Person*
Email Address*	A value is required.
Address
City
State
Zip Code
Business Phone*	A value is required.
Mobile Phone:

Current Insurance Company Information (if applicable)
Current Company
Current Limits
Expiration Date
Any claims in 5 years?	Yes No
If yes, please provide more information

Premises Location
Address
City
State
Zip Code

Employee Information
Number of Employees

Current Financial Information (This information may be given on the phone, please ask for an Agency Sales Director, call 570-226-4571).
Approximate Annual Payroll
Approximate Annual Revenue
Total Assets
Current Assets
Inventory (if applicable)
Cash (if applicable)
Current Liabilities
Total Liabilities
Total Revenue
Net/Income Loss

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Comments/Notes