Zolofra Insurance
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Toll Free: (888) 858-1777
Fax: (732) 334-0405

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What is your Specialty? (required)

Surgery (required)

How many consecutive years with full malpractice insurance coverage without a claim paid in excess of $25,000 – $50,000 (required)

Dedication (required)

Your current license number:

Do you employ any of the following? (please check)
 Chiropractor Nurse Anesthetist Nurse Midwife Nurse Practitioner Physician's Assistant Optometrist Podiatrist

What is the name of your current malpractice insurance carrier? (required)

If you do not currently carry malpractice Insurance, please advise why (to explain to the underwriters).

What is your current malpractice deductible? (required)

Expiration and Retroactive dates found on the cover page of your present policy. (required)

Please list Medical Societies, IPA’s or other Medical Group Affiliations to qualify for additional discounts:

Please give me quotes on liability limits of:
 $500,000/$1,500,000 1,000,000/$3,000,000

Please give me quotes on liability limits of: (required)


 Risk Management Program No Consent Option MagnaCare Member Part-time


Disclaimer Notice – The premiums quoted are estimates based on information you provided. This quotation does not constitute a contract of insurance, nor does it provide coverage for any loss or claim. Coverage can only be bound by an agent with a signed application and a down payment.

Please utilize the “Send” Button to send your form to our office. If the website does not allow you to submit the form, please print the page and fax it to 732.334.0405 or scan it into your computer and send it to ben@allprocoverage.com. Do not “Refresh” the page because all data entered onto the form will be lost.

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Zolofra Insurance Agency
P.O. Box 868
Oakhurst, NJ 07755
Toll Free: (888) 858-1777
Direct: (732) 542-1757
Fax: (732) 334-0405
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