Pharmacy Program Questionnaire

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* Required

Title

First Name *

Last Name *

Email Address *

Business Legal Name *

DBA Name *

Entity Type *

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 *

Square Footage of Entire Building *

Square Footage of Building You Occupy *

Any Other Occupants in Building? *

Please Check All Occupant Types *
No other Occupants
Retail
Parking
Business
Medical Facility
Other

Building Constuction *

Describe Property Adjacent to Building On All Sides *

Roof Type *

Year Building was Built *

Year Electrical Last Updated *

Year Plumbing Last Updated *

Year HVAC Last Updated *

Year Roof Last Updated *

Is Building Sprinklered? *

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 *

General Liability Coverage Desired? *

General Liability Limites Requested? *

Professional Liability Desired? *

Professional Liability Limits
$1000000
$2000000
None

Is Workers Compensation Coverage Desired? *

Esitmated Payroll?

Current Workers Compensation Insurance Company?

Current Workers Compensation Limits

Auto Liability Coverage Desired? *

Auto Liability Limits

Any Liquor Sales? *

If Yes, Please Provide Revenue Rrom Liquor Sales

Are Flu Shots or Any Vaccinations Given?

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 *

Current Insurance Company *

Policy Number & Effective Dates *

Do You Have A Written Pharmacy Department Policies and Procedures Manual? *

Do You Have a Training Program for Pharmacy Technicians? *

Do You Document All Potentially Litigious or Controversial Situations As Soon After Incident As Practical? *

Do You Have Systems For Recording Errors and Near Misses For Future Analysis and Quality Improvement? *

Do You Have a Computer System Linked to Patient Medical Information? *

Do You Allow Pharmacy Employees to Work Shifts Longer Than 10 Hours? *

Do You Allow Pharmacy Employees to Fill More Than 15 Perscriptions Per Hour? *

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? *

Is Your Business a Non-Store Retailer, Retailing Prescription and Non-prescription Drugs Via Electronic Home Shopping, Mail-Order or Direct Sale? *

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? *

Does more than 15% of revenue come from the lease, sell or rental of medical equipment?

Does the Business Sell Drugs Under Own Brand Name or Label? *

Does More Than 5% of Sales Come From Home Delivery? *

Is The Business Open 24 Hours Per Day? *

Does The Business Hire Security Guards? *

Does the Business Compound in Bulk, Manufacturer or Wholesales Any Drugs or Drug Products? *

Does More Than 1% of Your Total Prescription Sales Come From Compounds? *

Does Your Business Operate A Health Clinic? *

Phone: 205/414.8100 Address: 115 Office Park Drive, Suite 200, Birmingham, AL 35223