Walterry Insurance: Application for Business Insurance Program for Audiologists Name: Telephone: Address: Fax: City: State: Zip: County: Your Email Address: Years in Business: Type of Ownership: Individual Partnership Corporation Number of Audiologists: Number of Employees: Describe any losses in the last three years. Include date, type of loss and amount paid: Additional insured: Reason for additional insured: Policy effective date: Type of building construction (i.e., frame; masonry with wood roof; masonry with concrete or steel roof; fire resistive): Date Built: Sprinklered? Yes No No. of stories: Total area occupied (square feet): Do you own any other business operations? Yes No If yes, please describe: Limit of Insurance Building $ Business Personal Property $ Optional Coverages Workers' Compensation (not available in all states) Annual payroll of owners/officers $ All other employees $ Federal tax ID number: Commercial Umbrella Type of Insurance Company Policy Period Policy Number Limits Owned automobile Workers' Compensation Number of owned automobiles: Owned Automobiles (not available in all states) If coverage is desired, call 1-800-638-8791 for supplemental application. Back to Policy Features Copyright © 2005 Walterry Insurance Brokers [ Forms ] [ Contact Us ] [ Privacy Policy ] [ Home ]