Dental Office Application

Building Coverage (if you own building) ** Improvements and Betterments Contents Amount (without computer hardware/software) Computer Hardware / Software Amount Employee Benefit Liability Select Yes No Hired and Non-Owned Auto Liability Select Yes No Building Construction Select Frame Joisted Masonry Non-combustible Masonry Non-combustible Modified Fire-resistive Fire Resistive

Complete if building is over 25 years old

Does the building have aluminum wiring? Select Yes No Does the building have circuit breakers? Select Yes No

Year of updates for

Current Carrier Effective Date Have you had ANY losses in the past 3 years? Select Yes No If Yes please provide description

** Includes tenant's and condo owner's improvements (permanent additions or changes to your area at your expense, e.g., built-in cabinets, carpet, wallpaper, fixtures, etc.)

Do you currently have an EPLI Policy? Select Yes No Any losses in the past 3 years? Select Yes No If Yes please provide description

Do you currently have Flood Insurance? Select Yes No Any losses in the past 3 years? Select Yes No If Yes please provide description

Do you currently have your malpractice coverage with TPI? Select Yes No

(Defense costs, civil fines and penalties coverage for RAC Audits, HIPPA, Stark Law and EMTALA proceedings)

Do you currently have your malpractice coverage with TPI? Select Yes No

Do you currently have a Commercial Umbrella Policy? Select Yes No

Do you currently have an ERISA Bond? Select Yes No Exact Name of the Plan Amount of a bond that is required (10% plan assets):

Do you currently have a Workers Compensation Policy? Select Yes No Estimated Workers' Compensation Payroll (employees only) Federal ID# Have you had ANY losses in the past 3 years? Select Yes No Date, amount, description of any claims in the last three (3) years Provide names of officers/owners/partners (first name, last name, title (President, VP, etc.) ownership % Do any employees regularly use their vehicles or company owned vehicles for company business? Select Yes No Are injured workers treated in house or is there directed medical treatment? Select In House Directed medical treatment Will modified duty be offered to injured employees? Select Yes No Is Applicant engaged in any other type of business? Select Yes No Any work sublet with certificates of insurance? Select Yes No Any group transportation provided? Select Yes No Is there any volunteer or donated labor? Select Yes No If "Yes", please specify Do employees travel out of state? Select Yes No If "Yes", indicate states of travel and frequency Are employee health plans provided? Select Yes No Do any employees perform work for other businesses of subsidiaries? Select Yes No Do you lease employees to or from other employers? Select Yes No