Association Insurance Programs

Indiana State Chiropractic Association Business Insurance Quote Request

Thank you for completing the Indiana State Chiropractic Association (ISCA) quote request form. We will be in contact with you as soon as possible.

Are you an ISCA member?
Contact Name:
BusinessName:
Address:
City:
State:
Zip:
Phone:
Email Address:
Website:
Tax ID:
Business Entity Type:
Currently Insured?
If yes name of carrier:
Date coverage needed:
Years of industry experience:
Year business started:
Description of business operations:
Liability Limits desired:
Do you lease or own the space your office is in?
If owned please list the replacement cost value:
Business square footage:
Type of construction:
If other please describe:
Year built:
Building value:
Value of your business property & equipment:
Value of the stock / inventory:
Any equipment over $10000 in value?
If yes please list Type - Manufacturer - Age - Value:
Do you have vehicles titled to or leased in the name of your company to be insured?
If yes list make model VIN # Deductible:
Workers Compensation:
Number of employees & total payroll:
Number of owners / officers & total payroll:

Comments:
Do not enter anything in this field: