ChiroSecure Application

First Name

Middle Initial

Last Name

Mobile Phone

Office Phone

Fax Number

Personal Email Address

Office/Business Email Address

Website

Referred by

Practice Address

Mailing Address

check if the same as office address

Chiropractic College Attended

Graduation Date

Is your chiropractic license current?

Date First Licensed

Legal Business name of Primary Practice/Clinic:

Type of Practice

Do you own the Practice in which you work?

Yes No

Are you requesting an additional insured be added to your policy (additional charges will apply)?

Yes No

Additional insured name	Type
	Additional insured
Multiple licences please click here

ADDITIONAL CHIROPRACTORS List all other Chiropractors practicing in the same office and include all locations. Use separate sheet if needed
Name	Currently Insured
	Yes No

Policy Limits:

Select Supplemental Defense Limits:

Requested Effective Date:

Requested Coverage Type

Name	Price

Do you currently have an active Malpractice Insurance coverage?

Yes No

I, THE APPLICANT, DECLARE THAT I HAVE SIGNED OR TYPED MY NAME WHERE INDICTED BELOW, AND THAT THE STATEMENTS SET FORTH HEREIN ARE TRUE. I AGREE THAT IF THE INFORMATION SUPPLIED ON THIS APPLICATION CHANGES BETWEEN THE DATE OF THIS APPLICATION AND THE EFFECTIVE DATE OF THE INSURANCE, I WILL IMMEDIATELY NOTIFY THE COMPANY OF SUCH CHANGES, AND THE COMPANY MAY WITHDRAW OR MODIFY ANY OUTSTANDING QUOTATIONS, AUTHORIZATION OR AGREEMENT TO BIND THE INSURANCE. I UNDERSTAND THAT BY SIGNING THIS APPLICATION, NEITHER I NOR THE COMPANY ARE REQUIRED TO COMPLETE AND BIND THE INSURANCE, BUT IT IS AGREED THAT THIS APPLICATION SHALL BE THE BASIS OF THE CONTRACT SHOULD A POLICY BE ISSUED. ALL WRITTEN STATEMENTS AND MATERIALS FURNISHED TO THE COMPANY IN CONJUNCTION WITH THE APPLICATION ARE HEREBY INCORPORATED BY REFERENCE INTO THE APPLICATION AND MADE A PART HEREOF. THE EARLIEST EFFECTIVE DATE FOR WHICH A POLICY MAY BE ISSUED IS THE DATE THIS APPLICATION IS RECEIVED IN OUR OFFICE. I AGREE TO RECEIVE MY FREE SUBSCRIPTION TO DYNAMIC CHIROPRACTIC. OPT ME IN AND I ALLOW THE COMPANY TO COMMUNICATE WITH ME THROUGH EMAIL, FAX, PHONE, AND SMS/MMS MESSAGING OR OTHER TEXT MESSAGING PLATFORMS.

Applicant Signature:

Signature:
Clear

Use mouse to sign here.

Date:

Description	Current	Expected
Number of Animal Treatments per Month
% of Practice Spent in Animal Care