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*
Required
Title
DR
MISS
MR
MRS
MS
First Name
*
Last Name
*
Email Address
*
Business Legal Name
*
DBA Name
*
Entity Type
*
-- Please select --
Corporation
LLC
Individual
Other
Phone Number
*
Fax Number
*
Physical Address
*
City
*
State
*
Zip
*
Business Hours
*
Year Business Started
*
Federal Employer ID# (FEIN)
*
National Provider Identifier (NPI#)
*
NSC/TPRAN#
*
Business Owner Name
*
Pharmacist Name
*
Years of Experience as Pharmacist
*
Insurance Contact Person
*
Total Number of Employees
*
Number of Part-time Employees
*
Number of Full-time Employees
*
Number of Pharmacist
*
Estimated Sales ($)
*
Tenant or Building owner?
*
Replacement Cost Value of Building ($)
*
Replacement Value of ALL Contents/Inventory/Business Personal Property?
*
Property Deductible
*
-- Please select --
$500.00
$1000
$2500
$5000
Square Footage of Entire Building
*
Square Footage of Building You Occupy
*
Any Other Occupants in Building?
*
-- Please select --
Yes
No
Please Check All Occupant Types
*
No other Occupants
Retail
Parking
Business
Medical Facility
Other
Building Constuction
*
-- Please select --
Wood
Masonry (brick
cement etc)
Wood & Masonry
Steel
Masonry & Steel
Other
Describe Property Adjacent to Building On All Sides
*
Roof Type
*
-- Please select --
Wood
Shingle
Flat Tar
Metal
Other
Year Building was Built
*
Year Electrical Last Updated
*
Year Plumbing Last Updated
*
Year HVAC Last Updated
*
Year Roof Last Updated
*
Is Building Sprinklered?
*
-- Please select --
Yes
No
Check All that Apply
*
Burglar Alarm
Fire Alarm
Metal Bars on doors
Metal Bars on doorts
Burglar Alarm centrally monitored
Fire Alarm centrally monitored
None
Have You Incurred Any Claims in the Last 5 years? If Yes, Please Attach Loss Runs
*
-- Please select --
Yes
No
General Liability Coverage Desired?
*
-- Please select --
Yes
No
General Liability Limites Requested?
*
-- Please select --
Not requesting coverage
$300000
$500000
$1000000
$2000000
Professional Liability Desired?
*
-- Please select --
Yes
No
Professional Liability Limits
$1000000
$2000000
None
Is Workers Compensation Coverage Desired?
*
-- Please select --
Yes
NO
Esitmated Payroll?
Current Workers Compensation Insurance Company?
Current Workers Compensation Limits
-- Please select --
$300000
$500000
$1000000
$2000000
Auto Liability Coverage Desired?
*
-- Please select --
Yes
No
Auto Liability Limits
-- Please select --
Not Requesting Coverage
$300000
$500000
$1000000
$2000000
Any Liquor Sales?
*
-- Please select --
Yes
No
If Yes, Please Provide Revenue Rrom Liquor Sales
Are Flu Shots or Any Vaccinations Given?
-- Please select --
Yes
No
What Are The Certifications Of The Person Administering The Shots/Vaccinations?
Any Vehicles Used And Titled To The Business? If Yes Please Attach a List of the Vehicle Information, Cost New, Deductibles and Driver List
*
-- Please select --
Yes
No
Current Insurance Company
*
Policy Number & Effective Dates
*
Do You Have A Written Pharmacy Department Policies and Procedures Manual?
*
-- Please select --
Yes
No
Do You Have a Training Program for Pharmacy Technicians?
*
-- Please select --
Yes
No
Do You Document All Potentially Litigious or Controversial Situations As Soon After Incident As Practical?
*
-- Please select --
Yes
No
Do You Have Systems For Recording Errors and Near Misses For Future Analysis and Quality Improvement?
*
-- Please select --
Yes
No
Do You Have a Computer System Linked to Patient Medical Information?
*
-- Please select --
Yes
No
Do You Allow Pharmacy Employees to Work Shifts Longer Than 10 Hours?
*
-- Please select --
Yes
No
Do You Allow Pharmacy Employees to Fill More Than 15 Perscriptions Per Hour?
*
-- Please select --
Yes
No
Is Your Business Engaged In The Retail Sale of Prescription Drugs, Proprietary Drugs, and Non-prescription Medicines, and Which May Also Carry A Number of Related Lines, Such As Cosmetics, Toiletries and Novelty Merchandise?
*
-- Please select --
Yes
No
Is Your Business a Non-Store Retailer, Retailing Prescription and Non-prescription Drugs Via Electronic Home Shopping, Mail-Order or Direct Sale?
*
-- Please select --
Yes
No
Do More Than 15% of Total Gross Sales Come From Food Supplement Products Such as Nutrition Supplements, Health Supplements, Dieting Supplements and Body Enhancing Supplements?
*
-- Please select --
Yes
No
Does more than 15% of revenue come from the lease, sell or rental of medical equipment?
-- Please select --
Yes
No
Does the Business Sell Drugs Under Own Brand Name or Label?
*
-- Please select --
Yes
No
Does More Than 5% of Sales Come From Home Delivery?
*
-- Please select --
Yes
No
Is The Business Open 24 Hours Per Day?
*
-- Please select --
Yes
No
Does The Business Hire Security Guards?
*
-- Please select --
Yes
No
Does the Business Compound in Bulk, Manufacturer or Wholesales Any Drugs or Drug Products?
*
-- Please select --
Yes
No
Does More Than 1% of Your Total Prescription Sales Come From Compounds?
*
-- Please select --
Yes
No
Does Your Business Operate A Health Clinic?
*
-- Please select --
Yes
No