Physicians Insurance Premium Indication Request

    Physician’s Name

    Phone Number

    Street Address


    Email Address

    Fax Number

    What is your preference for communication?


    Who is the person responsible for insurance purchases

    So we know a little bit more about your insurance needs, please provide us the following information.

    What type of policy do you currently have?

    Claims MadeOccurrence

    What are your current limits of Professional Liability?


    What Earned Credits is your current company applying to your premium? Kindly check all that apply.

    Claim FreeRisk ManagementPart TimeNew PractitionerScheduled Credit

    When does your current policy renew?

    Do you currently have corporate coverage?
    If yes, is a separate or shared limit?

    Who is your current Professional Liability Insurance Company?

    What is your specialty?

    What is your current annual premium?

    Have any claims been made against you?
    If yes, please describe

    Please enter above characters:

    “Choosing insurance is a tremendous responsibility, and we are delighted to assist in that process. We consider your needs personally, and intelligently.”