Renewal Questionnaire for Business Owners Policy

Property

Is the Named Insured correct as shown?*

Yes

No

Is the property location a condominium unit?*

Yes

No

Do you own the unit (or your building, if not a condo)?*

Yes

No

Do you own it in the practice's name?

Yes

No

If you lease the location(s), have you made improvements to the space you lease (i.e. a build-out, carpeting, cabinetry, etc.)?*

Yes

No

Are the Building and Business Personal Property limits sufficient to replace the location in the event of a total loss?*

Yes

No

Are ALL locations of the practice listed on the policy, including off-site storage units or part-time locations?*

Yes

No

Are there any office-sharing arrangements with another practice or business?*

Yes

No

Have you formed a new corporate entity for any reason?*

Yes

No

Please describe:

If applicable, are the Certificate Holders listed on the policy still current? (Certificate Holders are entities which require evidence of insurance, such as a bank or landlord.)*

Yes

No

Not Applicable

Do you have any pieces of medical equipment (or inventory of medications) valued at over $100,000?*

Yes

No

With the advent of EMR, would you like a quote to increase your computer limits?*

Yes

No

Are there any property coverages or limits listed on your Summary of Insurance that need to be updated?*

Yes

No

Do you want to purchase (or increase) a daily limit for Loss of Business Income?*

Yes

No

Need more information

Would you like quotes to increase your Employee Theft, Forgery, and other crime coverages?*

Yes

No

Claims/Losses

During the year, did you report any claims or losses to the insurance company?*

Yes

No

Additional Information

Please tell us about any additions, deletions or changes you need on this (or another) policy. We will provide quotes prior to changing your policy.

You may also call MSVIA at 877-226-9357.

Name*

Title*

Organization Name*