Exposure Survey

Thanks for your interest. In order to provide an accurate quote, please complete the following questionnaire. If you have any questions, please call us at 215-491-2704 or email us at pharmacy@selzercompany.com. Thank you!

General Information

Legal Entity Name :

DBA :

FEIN# :

Years in Operation:

Please describe prior work experience and years licensed if you are a new company with less than 5 years of experience:

Type of Entity : CorporationLLCSole Proprietor/IndividualPartnership

Principal Business Address:

City :

State :

Zip:


Contact Person :

Email Address :


Phone # :

Cell # :

Fax#:

Association Membership (s):

How did you become aware of our Pharmacy Insurance Program:

# of Full Time Pharmacists :

# of Full Time Pharmacist Techs:


Total Full Time Employees :

Total Part Time Employees:

Estimated Annual Payroll: $

How are deliveries performed? : NoneEmployee VehicleCompany Vehicle (s)Other

Square Footage of Building Occupied by you:

What % of Building do you Occupy:

If you do not occupy 100% of building, what is the use of other space ? (Examples: shopping center, medical office building, 2nd floor professional office space, etc.)

Year building was constructed:

If building is over 30 years old, when were the below items updated/replaced?

Plumbing: Roof: Electrical: HVAC:


# of Stories:


Specify construction of building (check one only): Frame (Wood)Non-Combustible Masonry (Tilt-Up Concrete)Joisted Masonry (Brick)Non-Combustible (Steel)


Central Station Fire Alarm? YesNo

Central Station Burglar Alarm? YesNo

Sprinkler system covering 100% of premises? YesNo

Security Cameras ? YesNo

Have you had any insurance claim(s) in past 3 years? YesNo


Professional Liability

Type of Pharmacy (Total must = 100%):

Retail Pharmacy %

Staffing/Registry %

Closed Door Pharmacy %

Home Health Care Provider %

Compounding Specialty %

Mail Order Pharmacy %

Hospital Pharmacy %

Other: %

If Other, please describe:


Estimated Annual Gross Sales: $

Breakdown of Annual Gross Sales (Total must equal 100%)

Prescription Sales %

Durable Medical Equipment %

Over the Counter/Sundries %

Non-Sterile Compounding %

Vaccinations %

Sterile Compounding %

Medical Therapy Management %

Infusion Therapy %

Other: %

If Other, please describe:


Does the risk compound any of the following products?

Sustained-release products (e.g. theophyline, used for asthma) YesNo

Metered-dose inhaler (MDI) products YesNo

Products used for treatment of cancer YesNo

Dry powder inhaler (DPI) products YesNo

Transdermal delivery systems Patches (TDS) YesNo

If yes, please explain

Do you sell/rent any invasive durable medical equipment or devices? YesNo

Do you sell/rent any oxygen tanks/tents? YesNo

Do you RENT battery operated mobility scooters? YesNo

Do you sell any products under your own private label, if yes please list? YesNo

Any sale of prescription drugs filled by pharmacists in foreign countries? YesNo

Do you currently or plan to perform blood draws or blood testing? YesNo


Notes:




If you have any questions, please call us at 215-491-2704 or email us at pharmacy@selzercompany.com. Thank you!