Your Name(Required) First Last Full Mailing Address(Required) Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Full Primary Practice Address (if different) Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email(Required) Office Telephone Number(Required)FaxSecondary Practice Addresses (if any) 8810: Clercial and/or Office EmployeesGross annual payroll for clerical/office employeesPrimary Location(Required)Secondary Location(s)Total8832: Medical assistants, employee podiatrists, and other medical staff(Not including corporate officers or partners) Gross annual payroll for assistants/employee doctors etcPrimary Location(Required)Secondary Location(s)TotalCorporate officers or Partners(sole proprietors not eligible)Add Corporate Officers or Partners Name Gross Payroll Actions Edit Delete There are no Corporate Officers or Partners. Add Corporate Officer or Partner Maximum number of corporate officers or partners reached. Will the individuals named above included or excluded under the policy?(Required) Included Excluded 9915: Janitorial , Maintenance or Custodial (if any)Gross annual payroll for janitorial employeesPrimary LocationSecondary Location(s)TotalCurrent CarrierName of Current Carrier(Required) Amount of Annual Premium(Required)
