Your Name(Required)
Full Mailing Address(Required)
Full Primary Practice Address (if different)

8810: Clercial and/or Office Employees

Gross annual payroll for clerical/office employees

8832: Medical assistants, employee podiatrists, and other medical staff

(Not including corporate officers or partners)
Gross annual payroll for assistants/employee doctors etc

Corporate officers or Partners

(sole proprietors not eligible)
Name Gross Payroll Actions
Will the individuals named above included or excluded under the policy?(Required)

9915: Janitorial , Maintenance or Custodial (if any)

Gross annual payroll for janitorial employees

Current Carrier