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Medical Malpractice Quote
Medical Malpractice Quote
Contact Information:
First Name:
Last Name:
Daytime Telephone:
Evening Telephone:
Email:
Address:
City:
State:
Zip:
Practice Information:
Location Address:
How Long At This Location:
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+
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 insurance carrier
Limits of Liability:
$
- $
Deductible:
$
Renewal Date:
/
/
Premium:
$
Per Quarter:$
or Annually: $
Retroactive Date:
My desired effective date for
Medical Malpractice insurance is
Desired limits
(Check all you want quotes for)
$1,000,000 - $3,000,000
$2,000,000 - $4,000,000
$5,000,000
Other $
- $
Number of employed Physician Assistants/Nurse Practitioners
Physician/Surgeon Information:
Specialty:
Full Time
Part Time
Years Experience in Specialty:
Years Practicing in Community:
Board Certified?
Yes
No
Any previous claims activity?
Yes
No
If yes,
Doctor Name:
Date of Claim:
/
/
Patient Name:
Status:
Open
Closed Claim
Settlement
Judgment
Dismissal
If Open, Reserve Amount:
$
If Closed, Amount Paid:
$
Defense Costs:
$
Comments or Questions:
Deliver quote via:
E-Mail
Fax
Regular Mail
Telephone
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