Medical Malpractice Quote 
Medical Malpractice Quote
Contact Information:
1
First Name:
2
Last Name:
3
Daytime Telephone:
4
Evening Telephone:
5
Email:
6
Address:
7
City:
8
State:
9
Zip:
Practice Information:
10
Location Address:
11
How Long At This Location:
12
Check each of the following that applies to your practice:     Individual   Group Practice  Partnership
    Professional Corporation  Association  Affiliation
    Other:
13
Number of physicians in group 2-4     5-8     9+
14
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:
15
Current insurance carrier
16
Limits of Liability: $ - $
17
Deductible: $
18
Renewal Date: / /
19
Premium: $
Per Quarter:$ or Annually: $
20
Retroactive Date:
21
My desired effective date for
Medical Malpractice insurance is
22
Desired limits
(Check all you want quotes for)
    $1,000,000 - $3,000,000
    $2,000,000 - $4,000,000
    $5,000,000
    Other $ - $
23
Number of employed Physician Assistants/Nurse Practitioners
Physician/Surgeon Information:
24
Specialty:    Full Time         Part Time
25
Years Experience in Specialty:
26
Years Practicing in Community:
27
Board Certified? Yes         No
28
Any previous claims activity? Yes         No
29
If yes, Doctor Name:
30
Date of Claim: / /
31
Patient Name:
32
Status:     Open
    Closed Claim
    Settlement
    Judgment
    Dismissal
33
If Open, Reserve Amount: $
34
If Closed, Amount Paid: $
35
Defense Costs: $
Comments or Questions:
36
37
Deliver quote via: 
E-Mail Fax Regular Mail Telephone
No coverage of any kind is bound or implied by submitting information via this online form
We value your privacy. Every precaution has been taken to insure your 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 checking the box below 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

YES! I Agree