Start My Quote

Distributor Information

First name*

Last name*

Email*

Phone*

Entity Name*

Address*

Distributor Classification

Musculoskeletal Distributor

DME/HME Distributor

Musculoskeletal -What are the top 3 manufacturers that you represent?

DME/HME - Top 3 products that you sell (by revenue)

How many 1099 or W2s?*

Do you currently carry product or professional liability insurance? *

Yes

No

Any repackage or relabel?*

Yes

No

Do you import or export any products?*

Yes

No

Any surgeon on staff?*

Yes

No

Do you have a commercial auto policy?*

Yes

No

Do all labels on your products point back to the manufacturer? *

Yes

No

Have you ever had a product or medical-professional claim?*

Yes

No

Do you or your team have any patient contact?*

Yes

No

Do you provide home delivery?

Yes

No

bottom of page