Professional Liability Quote

Contact Information

Full Name:

First Last

Mailing Address:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone Number:

Best Time To Reach You:

Fax:

Email Address

Practice Information:

Primary Practice Address (if different from Mailing Address):

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Check each that applies to your practice:

Individual

Professional Corporation

Professional Association

Partnership

Affiliation

Group Practice

LLC (Limited Liability Corporation)

Other

Other Please Describe:

If Group Practice, how many physicians are in the group?

Entity Name(s)

Number of years in practice:

Medical License Number(s) / State(s):

Current Professional Liability Coverage

Current Insurance Carrier:

What type of coverage do you have?

Occurrence

Claims-Made

Modified Claims-Made

What limits of liability do you have? (Each Incident/Annual Aggregate)

Expiration Date:

Premium:

Retroactive Date:

Professional Information

Specialty:

Surgery

None

Minor

Major

Assist in Major

Number of hours worked per week:

Board Certified:

Yes

Claims History

Have you ever been involved in a Malpractice claim/suit/incident (including those dismissed or closed with no payment)?*

Yes

If yes, how many in the past 10 years?

Please provide the following for each claim:

Claim #1 - Claimant's Name:

Date of Incident:

Date Claim was Reported:

Current Status of Claim

Open

Closed

Amount of indemnity payment or award:

Amount of loss reserve or damages sought:

Description of Claim

Claim #2

Add Another Claim

Claim #2 - Claimant's Name:

Date of Incident:

Date Claim was Reported:

Current Status of Claim

Open

Closed

Amount of indemnity payment or award:

Amount of loss reserve or damages sought:

Description of Claim

Claim #3

Add Another Claim

Claim #3 - Claimant's Name:

Date of Incident:

Date Claim was Reported:

Current Status of Claim

Open

Closed

Amount of indemnity payment or award:

Amount of loss reserve or damages sought:

Description of Claim

Claim #4

Add Another Claim

Claim #4 - Claimant's Name:

Date of Incident:

Date Claim was Reported:

Current Status of Claim

Open

Closed

Amount of indemnity payment or award:

Amount of loss reserve or damages sought:

Description of Claim

Claim #5

Add Another Claim

Claim #5 - Claimant's Name:

Date of Incident:

Date Claim was Reported:

Current Status of Claim

Open

Closed

Amount of indemnity payment or award:

Amount of loss reserve or damages sought:

Description of Claim

Additional Comments:

Please give any additional comments or questions

No coverage of any kind is bound or implied by submitting information via this online form

Information from you and other sources, such as your driving, claims and insurance histories, may be used to calculate an accurate price for your insurance.
We will not distribute information to other parties other than for insurance underwriting purposes.
By submitting this form, you agree to release us from any liability should this information be accidentally viewed by others.

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