Data Breach | Cyber Liability Quote Form

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Requested Effective Date: *

Doctor/Owner's Name(s): *

Email: *

Phone: *

Preferred Method of Contact (select all that apply): *

Phone
Email
Text

Company (Legal) Name: *

Practice Name/DBA (if applicable):

Date Established

FEIN:

Number of Doctors in Practice: *

Physical Address: *

Address Line 1

Address Line 2

City

State

Zip Code

Mailing Address (if different):

Address Line 1

Address Line 2

City

State

Zip Code

How did you hear about us?

Additional information for my advisor:

Custom Captcha *

No time? No problem!

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We provide competitive quotes from multiple high quality carriers based on an "own occupation" definition with our agency's minimum recommended coverage. An advisor will contact you, after the initial proposal is delivered, to discuss further customization of the policy to meet your needs.

Legal Name: *

First

Middle

Last

Suffix:

Nickname (if applicable):

Date of Birth: *

Gender: *

Male
Female

Email: *

Phone: *

Preferred Method of Contact (select all that apply): *

Phone
Email
Text

Zip Code: *

Occupation:

Include specialty, if applicable

Current Employer:

Employment Experience (choose one):

New Graduate
Resident
Established in Practice

Do you work an average of 30 hours or more a week?

Are you a practice owner?

Disability Insurance requires both medical and financial underwriting. The following questions will allow us to provide a more accurate quote.If you prefer to answer these questions offline please call us at 972-663-5190 to speak to an advisor, or download a printable PDF and upload below or fax to 214.635.1099

Download Form Upload Form

Estimate Annual Earned Income:

Height:

Weight:

Are you currently taking any medications?

How did you hear about us?

Other information for my advisor:

Custom Captcha *

What is 7+4?

I am looking for...

Professional Liability (Malpractice) Insurance
Disability Insurance
Life Insurance
Health Insurance

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Legal Name: *

First

Middle

Last

Suffix:

Nickname (if applicable):

Email: *

Phone: *

Preferred Method of Contact (select all that apply) *

Phone
Email
Text

Requested Effective Date of Coverage: *

Specialty: *

New to Practice? *

Are you considering practice ownership?

Do you work an average of 30 hours or more a week?

Information for Professional Liability (Malpractice) Insurance Quote:

Preferred Professional Liability (Malpractice) Coverage Type *

Claims Made
Occurrence
Not Sure

Information for Disability Income Insurance Quote:

Monthly Disability Income Benefit Amount to Quote (select one):

Preferred Benefit Amount
Max Available Based on Income

Information for Discounts:

In the last 12 months, have you completed a risk management course?

How did you hear about us?

I'm also interested in:

Home & Auto Insurance
Flood Insurance

Other information for my advisor:

Custom Captcha *

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Requested Effective Date: *

Doctor/Owner's Name(s): *

Type of Business: *

Company Entity (Legal) Name: *

Email *

Phone *

Insurance Contact (if different):

Preferred Method of Contact (select all that apply): *

Phone
Email
Text

Zip Code: *

All Employees & Spouse/Dependents to be Covered:

Please provide a census that includes Employee (or Spouse/Dependent) Name, Date of Birth, and Gender (select one):

Send us your census via email (advisor@wallacesig.com), fax (214.635.1099) Download Form Upload Form
Enter information

How did you hear about us?

I'm interested in the following employee benefits:

Group Dental Insurance
Group Vision Insurance
Group Life Insurance
Group Short Term Disability Insurance
Group Long Term Disability Insurance
Voluntary employee paid insurance (cancer, critical illness, etc.)

Additional information for my advisor:

Custom Captcha *

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Download Form Upload Form

Requested Effective Date: *

Primary Policyholder's Name: *

First

Middle

Last

Suffix:

Date of Birth (highlight year to change): *

Gender: *

Male
Female

Tobacco Use? *

Email *

Phone *

Preferred Method of Contact (select all that apply): *

Phone
Email
Text

Zip Code: *

Type of Coverage Preferred (select one):

Additional - Type of Coverage Preferred (select one):

High Deductible/HSA Compatible
Lower Deductible with Co-pays
Show Me Options

All Individuals to be Covered:

1. Name:

First

Last

Date of Birth:

Gender:

Male
Female

Tobacco Use?

2. Name:

First

Last

Date of Birth:

Gender:

Male
Female

Tobacco Use?

3. Name:

First

Last

Date of Birth:

Gender:

Male
Female

Tobacco Use?

4. Name:

First

Last

Date of Birth:

Gender:

Male
Female

Tobacco Use?

5. Name:

First

Last

Date of Birth:

Gender:

Male
Female

Tobacco Use?

6. Name:

First

Last

Date of Birth:

Gender:

Male
Female

Tobacco Use?

How did you hear about us?

Additional information for my advisor:

Custom Captcha *

Prefer to complete offline? No problem!

Download Form Upload Form

We provide competitive quotes from multiple high quality carriers based on an "own occupation" definition with our agency's minimum recommended coverage. An advisor will contact you, after the initial proposal is delivered, to discuss further customization of the policy to meet your needs.

Legal Name: *

First

Middle

Last

Suffix:

Nickname (if applicable):

Date of Birth: *

Gender: *

Male
Female

Email: *

Phone: *

Preferred Method of Contact (select all that apply): *

Phone
Email
Text

Zip Code: *

Occupation: *

Include specialty, if applicable

Current Employer:

Employment Experience: *

New Graduate
Resident
Established in Practice

Do you work an average of 30 hours or more a week?

Are you a practice owner?

Disability Insurance requires both medical and financial underwriting. The following questions will allow us to provide a more accurate quote.If you prefer to answer these questions offline please call us at 972-663-5190 to speak to an advisor, or download a printable PDF and upload below or fax to 214.635.1099

Download Form Upload Form

Height:

Weight:

Are you currently taking any medications?

How did you hear about us?

Other information for my advisor:

Captcha *

Prefer to complete offline? No problem!

Download Form Upload Form

Requested Effective Date: *

Company Entity (Legal) Name: *

Practice Name/DBA (if applicable):

FEIN:

Doctor/Owner's Name(s): *

Insurance Contact (if different):

Email: *

Phone: *

Preferred Method of Contact (select all that apply): *

Phone
Email
Text

Physical Address: *

Address Line 1

Address Line 2

City

State

Zip Code

Mailing Address (if different):

Address Line 1

Address Line 2

City

State

Zip Code

Please provide an employee census that includes Employee Name, Date of Birth, and Gender as well as salary and occupation if group life and/or disability is requested (select one):

Send us your census via email (advisor@wallacesig.com), fax (214.635.1099) or upload Download Form Upload Form
Enter information

How did you hear about us?

I'm interested in the following employee benefits: *

Group Health Insurance
Group Dental Insurance
Group Vision Insurance
Group Life Insurance
Group Short Term Disability Insurance
Group Long Term Disability Insurance
Voluntary employee paid insurance (cancer, critical illness, etc.)

Other information for my advisor:

Custom Captcha *

Requested Effective Date: *

Doctor/Owner's Name(s): *

Insurance Contact (if different):

Email: *

Phone: *

Preferred Method of Contact (select all that apply) *

Phone
Email
Text

Company (Legal) Name: *

Practice Name/DBA (if applicable):

Date Established: *

FEIN(s):

Number of locations:

Primary Location Address: *

Address Line 1

Address Line 2

City

State

Zip Code

Mailing Address (if different):

Address Line 1

Address Line 2

City

State

Zip Code

Do you own any buildings?

Standard Business Owner's Policies Exclude Coverage for Losses Due to Floods & Earthquakes:

Would you like a quote for flood insurance?

Would you like a quote for earthquake insurance?

Number of Support Employees:

Annual Payroll, excluding owners/officers:

Number of Associates (Include W2 & Contractor):

Do you currently have a group professional liability policy?

Yes
No
Please Quote

Do you provide health insurance for your employees?

Does your business have a 401K or pension plan?

Do you own any vehicles in the name of the practice?

How did you hear about us?

I'm also interested in:

Additional information for my advisor:

Custom Captcha *

Prefer to complete offline? No problem!

Download Form Upload Form

Requested Effective Date: *

Doctor/Owner's Name(s): *

Email: *

Phone: *

Preferred Method of Contact (select all that apply): *

Phone
Email
Text

Company (Legal) Name: *

Practice Name/DBA (if applicable):

Date Established:

FEIN:

Physical Address: *

Address Line 1

Address Line 2

City

State

Zip Code

Mailing Address (if different):

Address Line 1

Address Line 2

City

State

Zip Code

Number of Support Employees: *

Number of Doctors on Staff (Including W2 & Contractor): *

Annual Payroll, without owners/officers: *

How did you hear about us?

Additional information for my advisor:

Custom Captcha *

Prefer to complete offline? No problem!

Requested Effective Date: *

Doctor/Owner's Name(s): *

Email: *

Phone: *

Preferred Method of Contact (select all that apply): *

Phone
Email
Text

Company (Legal) Name: *

Practice Name/DBA (if applicable):

FEIN:

Year Business Established:

Physical Address: *

Address Line 1

Address Line 2

City

State

Zip Code

Mailing Address (if different):

Address Line 1

Address Line 2

City

State

Zip Code

Square Feet Occupied:

Do you own the building? *

Is this a condo unit?

Amount of coverage for Business Personal Property:

contents, equipment, finish out, furniture, etc.

Do you own any vehicle in the name of the practice?

Standard Business Owner's Policies Exclude Coverage for Losses Due to Floods & Earthquakes:

Would you like a quote for flood insurance?

Would you like a quote for earthquake insurance?

How did you hear about us?

I'm also interested in:

Additional information for my advisor:

Custom Captcha *

Prefer to complete offline? No problem!

Download Form Upload Form

Requested Effective Date: *

Doctor/Owner's Name(s): *

Email: *

Phone: *

Preferred Method of Contact (select all that apply): *

Phone
Email
Text

Company (Legal) Name: *

Practice Name/DBA (if applicable):

Date Established *

FEIN:

Physical Address: *

Address Line 1

Address Line 2

City

State

Zip Code

Mailing Address (if different):

Address Line 1

Address Line 2

City

State

Zip Code

Number of Employees: *

Annual Revenue: *

How did you hear about us?

Additional information for my advisor:

Custom Captcha *

Prefer to complete offline? No problem!

Download Form Upload Form

Requested Effective Date: *

Doctor/Owner's Name(s): *

Email: *

Phone: *

Preferred Method of Contact (select all that apply): *

Phone
Email
Text

Company (Legal) Name: *

Practice Name/DBA (if applicable):

Date Established

FEIN:

Number of Doctors in Practice: *

Physical Address: *

Address Line 1

Address Line 2

City

State

Zip Code

Mailing Address (if different):

Address Line 1

Address Line 2

City

State

Zip Code

How did you hear about us?

Additional information for my advisor:

Custom Captcha *

Prefer to complete offline? No problem!

Download Form Upload Form

Legal Name: *

First

Middle

Last

Suffix:

Nickname (if applicable):

Date of Birth: *

Gender: *

Male
Female

Email: *

Phone: *

Postal Code: *

Preferred Method of Contact (select all that apply): *

Phone
Email
Text

How much coverage do you need? (select one): *

Enter Amount
Not sure, contact me to determine

Length of policy term (select all options of interest): *

10 Years
20 Years
30 Years
Lifetime

Life Insurance requires both medical and financial underwriting. The following questions will allow us to provide a more accurate quote.If you prefer to answer these questions offline please call us at 972.663.5190 to speak to an advisor, or download a printable PDF and upload below or fax to 214.635.1099

Download Form Upload Form

Height:

Weight:

Any tobacco use in the last 12 months?

Are you currently taking any medications?

Any family history of cancer, diabetes or heart disease?

How did you hear about us?

Additional information for my advisor:

Custom Captcha *

Legal Name: *

First

Middle

Last

Suffix:

Nickname (if applicable):

Email: *

Phone: *

Preferred Method of Contact (select all that apply): *

Phone
Email
Text

Home Address: *

Address Line 1

Address Line 2

City

State

Zip Code

Upload Current Policies

Click or drag files to this area to upload. You can upload up to 6 files.

How would you prefer to provide additional information

Via this online form
Have an advisor contact me

Standard Homeowner's Policies Exclude Coverage for Losses Due to Flood & Earthquake:

Would you like a quote for flood insurance?

Would you like a quote for earthquake insurance?

How did you hear about us?

I'm also interested in:

Disability Income
Life Insurance
Health Insurance
Business Owner's Insurance

Additional information for my advisor:

Custom Captcha *

Requested Effective Date: *

Doctor/Owner's Name(s): *

Email: *

Phone: *

Preferred Method of Contact (select all that apply): *

Phone
Email
Text

Company (Legal) Name: *

Practice Name (DBA if applicable):

FEIN:

Date Business Established: *

Physical Address: *

Address Line 1

Address Line 2

City

State

Zip Code

Mailing Address (if different):

Address Line 1

Address Line 2

City

State

Zip Code

Business Owner's Policy:

Includes Property, Liability and other important coverage for a business owner

Do you own the building?

Square Feet Occupied: *

Is this a condo unit?

Amount of coverage for Business Personal Property: *

In a worst case scenario: what would it cost to replace all contents, equipment, finish out, furniture, etc.

Standard Business Owner's Policies Exclude Coverage for Losses Due to Floods & Earthquakes:

Would you like a quote for flood insurance?

Would you like a quote for earthquake insurance?

Worker's Compensation:

Number of Support Employees:

Number of Doctors on Staff (Including W2 & Contractor):

Annual Payroll, excluding owners/officers:

Payroll Frequency (for pay-as-you-go)

Weekly
Bi-Weekly
Semi-Monthly
Monthly

How often do you pay your employees?

Other Coverage:

Do you pay for, or reimburse, associates for their malpractice?

Do you provide health insurance for your employees?

Does your business have a 401K or pension plan?

If you are too sick or hurt to work, do you have enough disability insurance to:

Keep your practice doors open?

Continue to make your loan payment(s)?

Do you own any vehicles in the name of the practice?

How did you hear about us?

I'm also interested in:

Additional information for my advisor:

Custom Captcha *

Legal Name: *

First

Middle

Last

Suffix:

Nickname (if applicable):

Email: *

Phone: *

Preferred Method of Contact (select all that apply) *

Phone
Email
Text

Specialty: *

First 6 months of Practice? *

Practice name:

Practice Zip Code (or City, State): *

Practice County (if known):

Are you an owner?

Requested Effective Date: *

Preferred Coverage Type *

Claims Made
Occurrence
Not Sure

Information for Discounts:

In the last 12 months, have you completed a risk management course?

How did you hear about us?

Other information for my advisor:

Custom Captcha *

Select Coverage to be Quoted (select all that apply):

Professional Liability (Malpractice) - Coverage for your work with patients
Disability Income - Protects your ability to continue to receive an income equal to your education and training in the event of an accident or illness

Legal Name: *

First

Middle

Last

Suffix:

Nickname (if applicable):

Email: *

Phone: *

Preferred Method of Contact (select all that apply): *

Phone
Email
Text

Specialty: *

University / Program Attended: *

Graduation Date: *

Employer/Practice Name (if known):

Professional Liability (Malpractice): The following selections will impact the company we recommend & future pricing. It is best to select only the items you know you will be performing.

Select all types of anesthesia you know you will administer:

Local
Nitrous
Oral Sedation (single dose of anxiety drug combined with nitrous)
* Multiple Dose Oral Sedation (multiple doses of anxiety drug with nitrous)
IV/IM Sedation
General Anesthesia

* Please note that a combination of drugs or cocktail given as a single dose in conjunction with nitrous is still single dose oral sedation.

How did you hear about us?

I'm Also Interested In (select all that apply:

Term Life Insurance
Health Insurance
Home/Renters & Auto Insurance

Additional information for my advisor:

Custom Captcha *

Data Breach | Cyber Liability Quote Form

Prefer to complete offline? No problem!

No time? No problem!

We provide competitive quotes from multiple high quality carriers based on an "own occupation" definition with our agency's minimum recommended coverage. An advisor will contact you, after the initial proposal is delivered, to discuss further customization of the policy to meet your needs.

I am looking for...

Prefer to complete offline? No problem!

Information for Professional Liability (Malpractice) Insurance Quote:

Information for Disability Income Insurance Quote:

Information for Life Insurance Quote:

Information for Health Insurance Quote:

Information for Discounts:

Prefer to complete offline? No problem!

All Employees & Spouse/Dependents to be Covered:

Prefer to complete offline? No problem!

All Individuals to be Covered:

Prefer to complete offline? No problem!

We provide competitive quotes from multiple high quality carriers based on an "own occupation" definition with our agency's minimum recommended coverage. An advisor will contact you, after the initial proposal is delivered, to discuss further customization of the policy to meet your needs.

Prefer to complete offline? No problem!

Standard Business Owner's Policies Exclude Coverage for Losses Due to Floods & Earthquakes:

Prefer to complete offline? No problem!

Prefer to complete offline? No problem!

Standard Business Owner's Policies Exclude Coverage for Losses Due to Floods & Earthquakes:

Prefer to complete offline? No problem!

Prefer to complete offline? No problem!

Prefer to complete offline? No problem!

Driver #2

Driver #3

Driver #4

Standard Homeowner's Policies Exclude Coverage for Losses Due to Flood & Earthquake:

Business Owner's Policy:

Standard Business Owner's Policies Exclude Coverage for Losses Due to Floods & Earthquakes:

Worker's Compensation:

Other Coverage:

Information for Discounts: