Dentists Benefits Insurance Company Northwest Dentists Insurance Company
BUSINESSOWNERS APPLICATION
GENERAL INFORMATION
1. Named insured:_________________________________________________________________________ 2. Requested effective date: ______________________ Referred by:______________________________ 3. Office address: __________________________________________________________________________ Street City State Zip County
4. Name of your legal entity (if any): _________________________________________________________ 5. Include any dba’s: _______________________________________________________________________
6. If you have a legal entity, do you want it included on this policy? Yes No
7. Telephone Number: (____) _____________ Fax Number: (____)_____________
8. Cell Phone Number: (____)_____________ Email: _____________________________________________ 9. Mailing Address: __________________________________________________________________________
Street City State Zip
10. Preferred Contact Method: Office Cell Email Other: __________________________
11. Number of full time employees:______________ Number of part time employees:_________________
Do you have any leased employees? Yes No
Do you have any independent contractors? Yes No
12. List any other business with which you or any family members have any financial interest:
________________________________________________________________________________________
Preferred billing plan: Annual Semi-annual* Quarterly*
Monthly – EFT only (subject to availability)
GENERAL LIABILTY COVERAGE
13. Requested Limits: $1,000,000 per claim / $2,000,000 aggregate
$2,000,000 per claim / $4,000,000 aggregate Other ____________________________________
14. If you lease your space, please provide name and address of building owner or landlord/property manager: ________________________________________________________________________________________
Building Owner or Landlord/Property Manager Street City State Zip
Please attach a copy of your lease agreement and a current photo of the building including one operatory.
DENTAL LABORATORY/DENTAL IMAGING SERVICES
15. Do you have Cone Beam imaging equipment in your office? Yes No
16. If yes, do you perform imaging services for others? Yes No
17. Do you own any other commercial property? Yes No
If yes, type of property: _________________
PROPERTY COVERAGE Coverage Limits Requested:
18. Building Replacement Value (if applicable): $___________________________
19. Business Personal Property (replacement value of contents, computers, equip, etc): $ ______________
Please break down the values of the following (included in your limit above):
Total value of tenant improvements: $_____________
Total value of computer equipment: $_____________ Are computers networked? Yes No
Value of Dental Equipment: $_____________ Total number of operatories: _____________
20. Is your office located in a condominium? Yes No
If yes, do you own the Condominium? Yes No
21. Do you have signs? Yes No Are the signs attached to the building: Yes No
Please provide value of signs: $______________________
22. Property Deductible: $500 $1,000 $2,500 $5,000 Other: _________________
23. Mortgagee or Loss payee (Bank, Finance Company, etc.):_______________________________________ Mailing Address:
________________________________________________________________________________________
Street City State Zip
24. Building Owner or Property Manager:________________________________________________________ Address: _________________________________________________________________________________
If you own your building:
Do you have tenants? Yes No
Do you require proof of general liability insurance from your tenants? Yes No
Are they required to list you as an additional insured? Yes No
Type of business operated by other building tenants:_______________________________________ 25. Your gross annual revenue: $_____________ Gross annual rental receipts (if any) $_______________ 26. Your estimated Annual Payroll: $_____________
27. Total amount of prescription drugs onsite: $____________ Please list types: ______________________ 28. Total amount of precious metals on site: $______________
PROPERTY INFORMATION – All information must be completed
29. Year Built: ________ If building is older than 25 years old, please provide the year the following updates were completed: Wiring________ Roof________ Plumbing________ Heating/Air Conditioning________ 30. Miles from fire station: ______________________ Feet from hydrant: __________________________
31. Building construction type: Frame Masonry Brick Veneer Reinforced Concrete Frame
Pre-Engineered Metal Frame Other: ____________________________
32. Roof construction is: _______ Age of roof: _______ Floor construction is:____________________ 33. Number of stories: _______ What floor is your office located? _______
34. Total square footage of your office: ________________ Building square footage: _______________
35. Alarms: Fire Burglar Combined fire/burglar
Local
Central
36. Is the building equipped with a sprinkler system? Yes No
37. Solenoid switch (automatic water shut-off valve): Yes No
38. If yes, is the system activated when practice is closed: Yes No
CRIME – Please complete all information
38. How do your store:
Prescription drugs Safe/vault Locked cabinet
Cash on hand Safe/vault Locked cabinet
Precious metals Safe/vault Locked cabinet
39. Who has keys or has access to your building after hours? ______________________________________ 40. What is their present position within your office? _____________________________________________
41. Is there a CPA audit at least once a year? Yes No
42. Who has authority to sign checks in your practice?
Name: ____________________________________ Position: ____________________________________ Name: ____________________________________ Position: ____________________________________ 43. Is there a monthly reconciliation of all accounts by a person who does not prepare and make deposits?
Yes No
44. Who is primarily responsible for the oversight of financial issues in your office?
Office staff Professional accountant or bookkeeper Family member
Myself Office manager Name: ___________________________________
OTHER COVERAGE – Please indicate limits desired
Accounts receivable: ____________________ ($25,000 included) Employee dishonesty: ___________________ ($25,000 included) Valuable papers: ________________________ ($10,000 included) Welfare & Pension Plan: _________________ ($25,000 included)
CLAIM HISTORY
List all losses during the last five years (please provide a current five-year loss history including the current year):
Are there circumstances of which you are aware that might give rise to a claim or suit even if you believe the
possibility of a claim or suit would be without merit? Yes No
If yes, please provide details in remarks section.
Any policy or coverage declined, cancelled or non-renewed? Yes No
If yes, please provide details in remarks section.
Current insurer: ___________________________________ Expiration date: _____________________________
I understand that this application does not bind or guarantee issuance of property or general liability insurance coverage.
I certify that as of the date of my signature below, I am not aware of any events, incidents or circumstances which I might expect to result in any type of claim or suit to be filed or asserted against me in any manner, except those specifically disclosed in this application for insurance.
I acknowledge that as a condition precedent to acceptance of this application and any future renewal thereof, an inquiry and investigation of my professional background, qualification and competence, including such other underwriting or claim matters as are deemed relevant, may be conducted by us or our duly authorized representatives. I expressly consent to any such inquiry and investigation and hereby authorize the release and exchange of information pertaining to such inquiry and investigation.
Submitted by:
___________________________________________________________________________________________
Signature Name and title (please print)
___________________________________________________________________________________________
Date Telephone number
FRAUD NOTICE – WHERE APPLICABLE UNDER THE LAW OF YOUR STATE
Any person who knowingly and with intent to defraud or solicit another to defraud an insurer (1) by submitting an application, or (2) by filing a claim containing a false statement as to any material fact, may be violating state law and may be subject to prosecution for insurance fraud.
FRAUD STATEMENT TO ARIZONA APPLICANTS
Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
FRAUD STATEMENT TO IDAHO, TENESSEE AND WASHINGTON APPLICANTS:
It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.
COMPLETION OF THIS FORM NEITHER BINDS COVERAGE NOR GUARANTEES A POLICY WILL BE ISSUED.
________________________________________________________________________________________
ARE YOU INTERESTED IN RECEIVING A QUOTE ON ANY OF THE FOLLOWING?
Earthquake: Yes No
Flood: Yes No
Employment Practices Liability: Yes No
Cyber Security: Yes No
Workers Compensation: Yes No
ERISA Yes No REMARKS: ______________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________
601 SW Second Ave, Portland, Oregon 97204 Phone: DBIC 1-800-452-0504 NORDIC 1-800-662-4075
Fax: 503-952-5276
