| Medical Malpractice Quote |
| Contact Information: |
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First Name: |
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Last Name: |
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Daytime Telephone: |
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Evening Telephone: |
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Email: |
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Address: |
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City: |
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State: |
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Zip: |
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| Practice Information: |
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Location Address: |
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How Long At
This Location: |
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Check each of the following that applies to your practice: |
Individual
Group Practice
Partnership
Professional Corporation
Association
Affiliation
Other:
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Number of physicians in group |
2-4
5-8
9+ |
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If in a group practice, is the group owned, managed or controlled
by any other healthcare entity? |
Yes
No
If "yes", name the entity and the relationship:
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Current insurance carrier |
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Limits of Liability: |
$
- $
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Deductible: |
$
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Renewal Date: |
/
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Premium: |
$
Per Quarter:$
or Annually: $
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Retroactive Date: |
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My desired effective date for
Medical Malpractice insurance is |
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Desired limits
(Check all you want quotes for) |
$1,000,000 - $3,000,000
$2,000,000 - $4,000,000
$5,000,000
Other $
- $
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Number of employed Physician Assistants/Nurse Practitioners |
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| Physician/Surgeon Information: |
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Specialty: |
Full Time
Part Time |
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Years Experience in Specialty: |
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Years Practicing in Community: |
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Board Certified? |
Yes
No |
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Any previous claims activity? |
Yes
No |
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If yes, Doctor Name: |
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Date of Claim: |
/
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Patient Name: |
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Status: |
Open
Closed Claim
Settlement
Judgment
Dismissal |
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If Open, Reserve Amount: |
$
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If Closed, Amount Paid: |
$
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Defense Costs: |
$
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Comments or Questions: |
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Deliver quote via: |
E-Mail
Fax
Regular Mail
Telephone |
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of any kind is bound or implied by submitting information via this online
form
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privacy and security. Our intent is to release information to you only.
We will not provide your data to any third party or group for sales, marketing,
or any other purposes. By submitting this form, you agree to release us from any liability should this information be accidentally viewed by others.
By completing this form, you are acknowledging your understanding
of and agreement with these terms
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