To obtain a quote (with no obligation), you must complete an application form. Submit your completed application in one of two ways:

Online... just fill in the fields below.

By mail or fax... Click Here to download and print a PDF application form.

Any questions? Contact us at the address below, please.

All supporting materials should also be sent to:

Judith Danioth-Fisher
McGovern & Fisher Insurance Agency Inc.
8960 Cayuse Trail
Bozeman, MT  59718
1-406-522-8989 (voice)
1-406-522-8991 (fax)

Applicant Instructions
Answer all questions. If the answer to a question is "none", state "none".
 Please read carefully the statement at the end of this application.
Please attach the following information:
  • A resume for each technician you employ
  • Sample of your service and preventative maintenance form
  • Sample of your hospital/clinic service and maintenance contract
  • A list of your testing equipment
  • A list of the new and used equipment you sell or distribute

1. Applicant Profile
 
Proposed Effective Date:
Name:
Mailing Address:
Location Address

(If Different):
Contact Person:
Title:
Telephone:
Fax:
Business is a:
Years in business under present name:
Describe present or prior affiliation with other firms:
Is your company a subsidiary of another?
Does your company have subsidiaries?


2. Loss History  
Any losses in the past five years?
Any outstanding claim reserves?
Has your company been named as a defendant in a lawsuit?

 

3. General Information
  
Hourly Service Rate ($):
Is your company a manufacturer authorized service representative?
If yes, advise percentage of total work performed (%):
Does your company service to the component level?
If yes, advise percentage of total work performed (%):
Does your company require or provide continuing employee education?
Do your technicians deal with a designated jobsite contact person?
Does your company provide consulting?
If yes, please describe:
Does your company sell new or used medical equipment?
If yes, list the type of equipment refurbished or rebuilt and note if warranties are offered:
Is equipment sold with the authorization of it's manufacturer?
If yes, please describe:


4. Exposure Data
 Current Receipts 
(Biomedical Technical Operations)
 Gross Receipts (Current Year): $
 Projected Receipts (Next 12 Months)
 Preventative Receipts: $
Repair Work: $
Consulting: $
Component Parts Sales: $
New Equipment Sales: $
Used Equipment Sales: $
Rental Equipment Income: $
Other Income: $
TOTAL Projected Income (Next 12 Months): $
Projected Payroll (Next 12 Months)
Technicians / Off Premises: $
Technicians / On Premises: $
Office Personnel: $
Consultants: $
Total Projected Payroll (Next 12 Months): $
Client Profile
 Hospitals (%):
Clinics (%):
Other (%):
Total (%): 100

 

5. Prior Insurance History
Current Liability Carrier
Premium:
Expiration Date:
Products Included:
Claims-Made Retro-Date:
1st Previous Carrier 
Premium:
Expiration Date:
Products Included:
Claims-Made Retro-Date:
2nd Previous Carrier
Premium:
Expiration Date:
Products Included:
Claims-Made Retro-Date:
If you have purchased claims-made insurance before, when did you first purchase it?


6. Limits of Liability Requested
 
$500,000 each occurrence/$500,000 general aggregate/$500,000 products/completed operations aggregate/$500,000 personal & advertising injury aggregate.
$1,000,000 each occurrence/$1,000,000 general aggregate/$1,000,000 products/completed operations aggregate/$1,000,000 personal & advertising injury aggregate.
Excess Liability Coverage (Umbrella)


7. Payment Preferences  
Annual Pay
25% down and finance the balance in 9 installments


8. The Finale
 
Use this space to provide any additional information you think appropriate:


By signing this application, I am attesting to the accuracy of the information provided. If any information provided by the applicant in this application is found to be false or misleading and would alter the Company's decision to provide insurance coverage applied for, it is agreed between the Company and the applicant that the coverage, if under binder or policy, is subject to immediate cancellation.


Signature of Applicant: *


 ______________________________________________

Date: ___________________________________

Title: ___________________________________
       (owner, partner, officer...)

*Signing this application does not bind the applicant or the company to complete the insurance.