Your Name (required)
City, State, Zip (required)
Contact Name (required)
Your Email (required)
PROFESSIONAL LIABILITY INSURANCE HISTORY
What is your Specialty? (required)
Please SelectSurgeryNo SurgeryMinor Surgery
How many consecutive years with full malpractice insurance coverage without a claim paid in excess of $25,000 – $50,000 (required)
Please SelectFull TimePart Time
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:
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.
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Your First Name (required)
Your Last Name (required)
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Name Of Your Company or type of business if seeking commercial insurance (required)
Street Address (required)
Zip Code (required)