Business Insurance Quote Form

To receive a free quote, call toll free 800-769-2000, ext. 8180. Or fill in the information below. Information is required unless noted as optional. When finished, click the "Submit" button at the bottom of the page.

All fields marked with * are required.

Quote Selection

Select the product(s) for a quote:(Optional)

Business Owner's Protection Worker's Compensation Insurance Other (Business auto, flood, earthquake, etc.)

Contact Information

Doctor's First Name: *

Middle Initial: (Optional)

Last Name: *

Practice Name (or DBA): *

Mailing Address: *

P.O. Box, Apt., Ste., etc. (Optional):

City: *

State: *

Please contact NCMIC to inquire about availability of coverage in Florida. 1-800-769-2000, ext 8180 or agents@ncmic.com.

ZIP: *

Phone: *

Practice Fax (Optional):

Email: *

Is your practice address the same as the mailing address?: *

Yes No

Address

Practice Address: *

P.O. Box, Apt., Ste., etc. (Optional):

City:*

State:*

Please contact NCMIC to inquire about availability of coverage in Florida. 1-800-769-2000, ext 8180 or agents@ncmic.com.

ZIP:*

What is the best time to contact you?: *

Practice Information

Practice Type: *

Sole proprietor - Owned and operated by a single business owner (Individual) LLC - Limited Liability Company Corporation - A separate legal entity that is incorporated by law PLLC - Professional Limited Liability Company Partnership - An association of 2 or more persons carrying on a business as co-owners for profit Other Other

Number of years you've been practicing: *

Gross annual practice receipts: *

Percent revenue from supplement sales: *

Do your business operations involve growing, storing, selling, dispensing, manufacturing/processing or otherwise providing access to medically-prescribed or recreational marijuana? *

Yes No

Facility Information

Do you own the building? *

Yes No

Building Info

Total square feet of building: *

Replacement cost of building (Optional):

Is building ownership the same as chiropractic business ownership? *

Yes No

Building Construction: *

Frame - Primarily wood frame construction with siding or stucco on exterior Brick - Exterior wall is primarily brick, concrete, or stone Concrete - Interior and exterior construction is built primarily of concrete block Other - Includes: metal frame, structural steel, fire resistive

Year built: *

Square feet of your practice: *

Updates

Year of last updates to: (Optional)

Roof:
Electrical:
Plumbing:
Heating:

Number of stories: *

Value of contents (Optional):

NCMIC provides the insurance quote based on replacement cost of contents. Please use a dollar amount based on what it would cost to replace the items today if purchased new.

Value of tenant improvements (Optional):

Example: Flooring, walls, etc.

Coverage and Quote Information

Have you filed a claim for your office insurance in the last 5 years? *

Yes No

Claims

How many claims? *

Date of claim (mm/dd/yyyy): *

Please provide reason: *

Amount paid: *

Choose a liability coverage amount: *

$1,000,000 per claim / $2,000,000 per year $2,000,000 per claim / $4,000,000 per year

Do you currently have Business Owners' Coverage? *

Yes No

Carrier

Insurance carrier name: *

Other Insurance Carrier Name: *

Renewal date (mm/dd/yyyy) (Optional):

Do you have multiple practice locations? *

Yes No

Other Locations An NCMIC insurance representative will contact you for information about your other locations.

Employee Information

Total number of employees: *

Are owners/principals included? *

Yes No

Estimated Owners/Principals Annual Payroll: *

Estimated Employee Annual Payroll: *

Employer Federal I.D. Number: *

Have you had any workers' comp. claims in the past 5 years? *

Yes No

Workers Comp

How many claims? *

Date of claim (mm/dd/yyyy): *

Amount paid: *

Comments

Additional information or comments (Optional):

(maximum 2000 characters)

Once your completed information is received, a representative will contact you.

Questions? Call toll free at 1-800-769-2000, ext. 8180.

Business Insurance Quote Form

Customized Coverage Designed for Chiropractors and Naturopaths