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Underwriting Information
Company Name
Your Name
Email Address
Email (for accuracy)
Street Address
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Phone (daytime)
Ext.
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Fax
About Your Business
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Do you currently have
Professional Liability Owners
insurance?
Yes
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Number of Owners or Officers?
If "Yes", when does your current policy expire?
If "Yes", who are you currently insured with?
Type of Business
Description of Business Operations:
Do you currently have
Business Liability Owners
insurance?
Yes
No
Type of Insurance Desired
Errors and Omissions
Malpractice
Directors and Officers
Not Sure
Year Business Established
Number of Locations
Number of Employees
Approximate Annual Gross Revenue
Approximate Amount of Desired Insurance
Has your company submitted any claims in the last 3 years?
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If "Yes", briefly explain:
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Tampa Commercial Insurance (An Affiliate of Insurance Office of America)
4915 West Cypress Street | Tampa, FL 33607 | Phone: 813-358-4330 | Fax: 813-637-8484
Email: paul.allard@ioausa.com | Florida Insurance License #: W516422