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 Please mail an application packet to me.
 Please call me.
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Applicant Information:

Your name:  
Your e-mail address:  
Street address:  
City:  
State:       Zip Code:
Phone number:  
Fax number:  

How long at this location?  

Practice Information:

Check each of the following that applies to your practice:

    Individual
    Group Practice
    Partnership
    Professional Corporation
    Association
    Affiliation
    Other:

Number of
physicians in group:   2-4     5-8     9+   Solo

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:

Current Professional Liability Insurance Coverage:

Current insurance carrier:  
Limits of Liability: $ per Claim $ Aggregate
Deductible: $
Renewal Date: //
Premium: $
Per Quarter: or Annually:
Retroactive Date: //

Requested Coverage:

My desired effective date for
Medical Professional Liability Insurance is:   //

Desired limits:
    $1,000,000 - $3,000,000
    Other $ per claim $ aggregate

Number of employed:

Physician Assistants: Nurse Practitioners:

Physician/Surgeon Information:

Are you entering Private Practice for the first time?

Yes No

Specialty:

Full Time         Part Time

If Part Time How Many Hours?

0-10 10-2020-30N/A

Years Experience in Specialty:
CME Hours in the Past Three Years:
Board Certified?    Yes       No
If No, Board Eligible?    Yes No N/A
Date if Eligible: //
Any previous claims activity? Yes         No
If yes and a group, Doctor Name:
Date of Claim: / /
Patient Name:
Status:
    Open
    Closed Claim
    Settlement
    Judgement
    Dismissal
    N/A

If Open, Reserve Amount: $
If Closed, Indemnity Paid: $
               Defense Costs (If Known): $

Any additional comments:

If you have more then one claim, please list the highest claim and we will contact you for the remaining claim information.