Practice Information

Check each that applies to your practice

Individual Group Practice Partnership Professional Corporation Association Affiliation Other:

 

Current Professional Liability Coverage
Current Insurance Carrier:
Limits of liability:	$ per claim   $ aggregate
Effective Date:	Premium: $
Retroactive Date:

 

Professional Information
Occupation:	Practice Operates:	Board Certified
Specialty:	Full Time Part Time	Yes     No

 

Claims History This information is kept strictly confidential

Claim #1	Claim Status: Closed   Open
Patient Name:	Date of occurrence:
Insurance Carrier:	Location of occurrence:
Allegations:
Amt. paid on your behalf:	$  Amt. reserved on behalf: $

Claim #2	Claim Status: Closed   Open
Patient Name:	Date of occurrence:
Insurance Carrier:	Location of occurrence:
Allegations:
Amt. paid on your behalf:	$  Amt. reserved on behalf: $

Claim #3	Claim Status: Closed   Open
Patient Name:	Date of occurrence:
Insurance Carrier:	Location of occurrence:
Allegations:
Amt. paid on your behalf:	$  Amt. reserved on behalf: $

 

Additional Comments

Please give any additional comments you feel appropriate for this premium indicator. If you have additional information where there was not enough space, please enter them here.

Please click on the "Submit Form" button to send your request.
One of our representatives will respond to your submission as soon as possible.