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 Office Package and Workers Compensation Questionnaire.

1. OFFICE PACKAGE AND WORKERS’ COMPENSATION QUESTIONNAIRE
Legal Business Name:
Property Address:
Mailing Address:
Contact Phone: Email:
Legal Entity: Individual Corporation Partnership LLC Other
Years of Experience: Years in Business: Is this a new venture?
Interest Type: Owner Occupied Tenant Lessor Amount of your gross sales:
PROPERTY INFORMATION – LOC 1 Requested Effective Date:
Is this a Condo Unit? If yes, does the Condo Assn cover the building? If yes, do you own the unit?
Building Value:
Replacement
Value Contents:
Replacement Value
Build-Out:
Construction: (check one) Frame walls and wood roof Concrete block with wood beam roof
Poured concrete with steel beam roof Concrete block with steel beam roof
Date of Original Construction: # of Stories: Total Square Footage: Sq Foot Occupied:
Fire Sprinkler System? Central Station Alarm? Monitored by? Distance to Fire Hydrant:
Year Updated:
Plumbing: Roof: Electric: A/C: Renovations underway/anticipated:
Name of Current Insurance Carrier: Prior carrier policy number, if known:
Have you been cancelled or non-renewed? If so, please please provide an explanation. :
Any Claims in last 5 years: If yes, briefly describe:
Please attach the names and addresses of any Mortgagees, Loss Payees, Additional Insured’s, or Certificate Holders to be included.
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
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2. PROPERTY INFORMATION – LOC 2 Requested Effective Date:
Is this a Condo Unit? If yes, does the Condo Assn cover the building? If yes, do you own the unit?
Building Value:
Replacement
Value Contents:
Replacement Value
Build-Out:
Construction: (check one) Frame walls and wood roof Concrete block with wood beam roof
Poured concrete with steel beam roof Concrete block with steel beam roof
Date of Original Construction: # of Stories: Total Square Footage: Sq Foot Occupied:
Fire Sprinkler System? Central Station Alarm? Monitored by? Distance to Fire Hydrant:
Year Updated:
Plumbing: Roof: Electric: A/C: Renovations underway/anticipated:
Name of Current Insurance Carrier: Prior carrier policy number, if known:
Have you been cancelled or non-renewed? If so, please please provide an explanation. :
Any Claims in last 5 years: If yes, briefly describe:
PROPERTY INFORMATION – LOC 3 Requested Effective Date:
Is this a Condo Unit? If yes, does the Condo Assn cover the building? If yes, do you own the unit?
Building Value:
Replacement
Value Contents:
Replacement Value
Build-Out:
Construction: (check one) Frame walls and wood roof Concrete block with wood beam roof
Poured concrete with steel beam roof Concrete block with steel beam roof
Date of Original Construction: # of Stories: Total Square Footage: Sq Foot Occupied:
Fire Sprinkler System? Central Station Alarm? Monitored by? Distance to Fire Hydrant:
Year Updated:
Plumbing: Roof: Electric: A/C: Renovations underway/anticipated:
Name of Current Insurance Carrier: Prior carrier policy number, if known:
Have you been cancelled or non-renewed? If so, please please provide an explanation. :
Any Claims in last 5 years:
If yes, briefly describe:
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3. PROPERTY INFORMATION – LOC 4 Requested Effective Date:
Is this a Condo Unit? If yes, does the Condo Assn cover the building? If yes, do you own the unit?
Building Value:
Replacement
Value Contents:
Replacement Value
Build-Out:
Construction: (check one) Frame walls and wood roof Concrete block with wood beam roof
Poured concrete with steel beam roof Concrete block with steel beam roof
Date of Original Construction: # of Stories: Total Square Footage: Sq Foot Occupied:
Fire Sprinkler System? Central Station Alarm? Monitored by? Distance to Fire Hydrant:
Year Updated:
Plumbing: Roof: Electric: A/C: Renovations underway/anticipated:
Name of Current Insurance Carrier: Prior carrier policy number, if known:
Have you been cancelled or non-renewed? If so, please please provide an explanation. :
Any Claims in last 5 years: If yes, briefly describe:
PROPERTY INFORMATION – LOC 5 Requested Effective Date:
Is this a Condo Unit? If yes, does the Condo Assn cover the building? If yes, do you own the unit?
Building Value:
Replacement
Value Contents:
Replacement Value
Build-Out:
Construction: (check one) Frame walls and wood roof Concrete block with wood beam roof
Poured concrete with steel beam roof Concrete block with steel beam roof
Date of Original Construction: # of Stories: Total Square Footage: Sq Foot Occupied:
Fire Sprinkler System? Central Station Alarm? Monitored by? Distance to Fire Hydrant:
Year Updated:
Plumbing: Roof: Electric: A/C: Renovations underway/anticipated:
Name of Current Insurance Carrier: Prior carrier policy number, if known:
Have you been cancelled or non-renewed? If so, please please provide an explanation. :
Any Claims in last 5 years: If yes, briefly describe:
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4. WORKERS’ COMPENSATION INFORMATION
Requested Effective Date:
What is your Federal Tax Id #:
How many total
employees do you have? How many are part-time?
What is the gross salary for all
employees, excluding Officers: What is the gross salary for Officers?
Are Officers/Owners to be
included or excluded?
List the names of all
Officers/Owners:
Name of current insurance Carrier:
Any claims?
If so, please attach a copy of the loss runs.
Are health benefits provided? Out of state travel: Do employees dispose of hazardous materials?
Salary for those doing grinding of lenses: 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
UMBRELLA INFORMATION
UMBRELLA LIMITS: $1,000,000 $2,000,000 $3,000,000 Other
Notes: