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Workers Compensation Questionnaire - Chiropractic Insurance

If you are looking for the Chiropractic Insurance the Chiropractic Protector Plan is the best you can get. It offers professional liability, practice insurance and risk management benefits for chiropractic physicians nationwide. Here is the application for Workers Compensation Questionnaire.

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Workers Compensation Questionnaire - Chiropractic Insurance

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  1. Chiropractic Protector Plan® P.O. Box 173166 Tampa, FL 33672 Toll-Free: 844-239-1719 Fax: 813-222-4370 Email: info@cppinsurance.com Visit our Website: www.cppinsurance.com CA License No: 0G51291 WORKERS’ COMPENSATION QUESTIONNAIRE Requested Effective Date: Legal Business Name: Property Address: Mailing Address: Contact Phone: Email: Legal Entity: Individual Corporation Partnership LLC Other Years of Experience: Amount of your gross sales: Years in Business: Is this a new venture? Location(s): 1. 2. 3. How many total employees do you have? What is your Federal Tax Id #: What is the gross salary for all employees, excluding Officers: Are Officers/Owners to be included or excluded? How many are part-time? What is the gross salary for Officers? List the names of all Officers/Owners: Any claims? If so, please attach a copy of the loss runs. Name of current insurance Carrier: Have you been cancelled or nonrenwed? If so, please provide an explanation. : Are health benefits provided? Salary for those doing grinding of lenses: Out of state travel: Do employees dispose of hazardous materials? All other employees: LIMITS: $100,000/$500,000/$100,000 $500,000/$500,000/$500,000 $1,000,000/$1,000,000/$1,000,000 Signature: Date:

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