Dentist – Full Questionnaire

Business Name

Phone

Legal Entity

Year Business Started

Describe operations

Braces offered as a service

Any claims/losses in the last 5 years

Annual revenue for the business

Current insurance carrier

Total Dollar Value of Business Equipment: (Treatment Chair, Surgery Instruments, Mobile Treatment units, X-ray machine, Suction devices, etc.)

Total number of Full-Time W2 employees

Total number of Part-Time W2 employees

Total number of 1099 contractors

Property Address

Own or Rent?

Square footage

Construction Type

Year Built

Building Value

Contents Value

Plumbing type and year updated

Sprinkler system

Alarm system