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Request a Quote

Biotech, Medtech or Life Sciences Insurance Questionnaire

General Application Information
(Required *)

How did you hear about MOODY Tech Insurance?
Complete Business Name: *
Mailing Address/Street:
City/State/Zip:
Location Address/Street (if different from mailing):
City/State/Zip:
Primary Contact Name: *
Contact Title:
Phone Number: *
Fax Number:
Email Address: *
Web Site Address:
Type of Entity
(Sole Proprietor, Corporation, Partnership, LLC, etc):
Federal ID Number:
Type of Business:
(Describe typical services performed, customers served, products provided, etc.) :
   
Sales Breakdown by % of revenue

% Lab R&D- Grants, or other Educational Research Funding
% Product Revenue
% Service Revenue

Total for the breakdowns above (should add up to 100%)

Years In Business:
If New Venture, prior experience:
Do you work or sell product overseas? Yes       No
   
Current Insurance Information
Current Insurance Carrier (Name of Company, not Agency):
How Long Insured:
Date(s) Policy(s) Expire:
Reason for Considering Change:
   
Location / Building Information
  LOCATION 1 LOCATION 2 LOCATION 3
Construction:
# of Stories:
Year Built (approx.):
If over 30 years old, years of updating for
Wiring
Heating
Plumbing
Roof
Wiring
Heating
Plumbing
Roof
Wiring
Heating
Plumbing
Roof
Square Footage:
Owner? No Yes No Yes No Yes
Tenant? No Yes No Yes No Yes
Alarms? Burglar
Fire
Local
Central Station		 Burglar
Fire
Local
Central Station 		Burglar
Fire
Local
Central Station
Sprinklers? No Yes No Yes No Yes
   

Coverage/Rating Basis Information
Property
Replacement Value of Contents:
Should include Leasehold Improvements(may also be included in building so obtain a breakdown), Leased Property, Inventory, Furniture/Fixtures, Equipment, Printed Materials, Consumables, Property of Others
 $
Replacement Value of Building, if applicable: $
Replacement Value of Computer Hardware: $
Valuable Papers: $
Property Used at Exhibitions, Fairs or Tradeshows: $
Other property or equipment (specify what): $
Business Property Used/Transported/Stored Off-Premises: $
Replacement Value of Other Office Contents: $
 
General Liability
Each Occurrence Limit Desired: $1,000,000
$2,000,000
Other? $
Estimated Annual Gross Revenues: $
Estimated Annual Total Payroll $
Number of Full Time Employees:
Number of Part Time Employees:
Do you use sub-contractors?: No Yes

If yes, for what purposes?:

Do you require sub-contractors to carry insurance and do you obtain certificates of insurance?:

No Yes
 
Worker's Compensation by State
State Classification/Duties:   Est. Annual Payroll:  Number of Employees:
$
  Classification/Duties   Est. Annual Payroll:  Number of Employees:
$
  Classification/Duties   Est. Annual Payroll:  Number of Employees:
$
  Classification/Duties   Est. Annual Payroll:  Number of Employees:
$
 
Owner/Officer Information
Name   Title  Duties  Incl/Excl
Name   Title  Duties  Incl/Excl
Name   Title  Duties:  Incl/Excl
Name   Title  Duties  Incl/Excl
 
Automobile
Comprehensive Deductible: $
Collision Deductible: $
Rented Vehicles used or Employee Vehicles Used in Business? No Yes

If yes, number of rental car days/year:

If non-owned, how many employees drive their cars frequently for company business:
If any key employees have company vehicles and do not buy a personal auto policy for their protection while driving for personal use (Drive Other Car Coverage ), list their names:
   
Owned Vehicle Schedule
NOTE: You may complete with Vehicles and Drivers below, or fax us your list at 301-417-0040

YEAR

MAKE / MODEL

COST NEW

GARAGING CITY/STATE

RADIUS

USE in YEARS

Drivers Schedule (if you own vehicles)
(List all employees who drive any vehicle on company business).

NAME

DATE OF BIRTH

DRIVERS LIC #

STATE

ACCIDENTS/VIOLATIONS WITHIN LAST 3 YEARS
 
Prior Claim/Loss Information

Have you had any prior claims or losses? No Yes

IMPORTANT: IF YOU ANSWERED YES ABOVE, PLEASE CALL YOUR CURRENT AGENT AND REQUEST A COPY OF YOUR CLAIMS HISTORY (OR “LOSS RUNS”) FOR THE LAST THREE YEARS FOR ALL OF YOUR POLICIES.
 
Other Optional Coverage to Consider
Do you need coverage for trips or work outside the United States? No Yes
Would you like an optional Umbrella Quote? No Yes
Would you like an Employee Benefits Quote (health, life, disability, long-term care)? No Yes
Would you like an Employment Practices Liability Quote? No Yes
Interested in Any Other Coverage Not Shown Above?
 
        



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