Current Insurance Information

Current Insurance Carrier?

Is your coverage occurrence or claims-made?

What Limits do you carry?

What are the effective dates of your coverage?

What is your retroactive date? (Claims-made only)

Prior Acts Desired? Yes  No

What is your annual Premium?

This information will allow us to provide you with a tentative premium indication for the limit(s) you choose.

$1,000,000/$3,000,000 Claims Made

Are you a Newly Practicing Physician? Yes   No
If yes, year you completed residency/fellowship

Is practice Full Time? Yes  No
If no, number of hours/week

Do you have any Physician Assistants (PA)? Yes  No

Do you have any Medical Assistants (MA)? Yes  No

Are you a member of a formal group or partnership?  Yes  No
If yes, number of physicians in group

Are you a member of a Professional Medical Society or Organization?
Yes  No
If yes, name of organization

Any paid claims within 10 year period with indemnity payment over $100,000 and no more than 2 open/closed in the past 5 year period?
Yes  No
Closed with payment
Closed no payment
Open