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Brown & Brown EWC Form

EWC Insurance Application

Items marked with * are required

Basic Information

7. If current Professional Liability coverage is in force for these activities please specify:

Revenue / Limit / Requested Deductible

Gross Annual Revenue Limits Deductible Abuse & Misconduct
8.

Professional Liability


True
False

10. We do NOT perform any of the following:

  1. Surgery or assist in surgery
  2. Render medical care, including but not limited to the diagnosis of any medical disorder, cancer, or disease
  3. Practice obstetrics or gynecology, including vaginal rejuvination or prenatal care
  4. Perform any injections
  5. Perform hormone therapy
  6. Perform laser service
True
False

True
False

True
False

True
False

Prior History


True
False

True
False

Warranty


True
False

Property Section

17. Building Information:

18. If building is over 20 years old, when were the following upgraded?


Yes
No

Yes
No

Coverage Limits Desired

Coverage Limit Deductible
20. Contents
21. Tenant Improvements
22. Building
23. Business Income
24. Extra Expense

Claims

Workers Compensation

Payroll Number of Employees
27. Waxing Specialist
28. Clerical

Jon Perrillo

Brown & Brown Insurance

Fort Lauderdale Division of Brown & Brown of Florida Inc.

1201 W. Cypress Creek Road, Ste 130

Fort Lauderdale, FL 33309

Direct: 954.331.1425 Toll Free: 800.634.5033 Fax: 954.776.4446

SelectNewBusiness@bbftlaud.com www.bbftlaud.com