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Medical Malpractice Premium Indicator

We would like to provide you with a free, no-obligation medical malpractice premium indicator. Please provide as much information possible for the most accurate premium. This information will be kept confidential and will be used for this purpose only.

General Information Your Name: Your E-Mail Address: Primary Practice Address: City: State:  Zip:  Office Phone:   Office Fax: Date of Birth:   # of Years in Private Practice:

 

Practice Information Check each that applies to your practice Individual Group Practice Partnership Professional Corporation Association Affiliation Other:

 

Current Professional Liability Coverage Current Insurance Carrier: Limits of liability: $ per claim       $ aggregate Effective Date:     Retroactive Date: Premium: $

 

Physician/Surgeon Information Specialty: Practice Operates: Board Certified Full Time   Part Time Yes   No

 

Claims History This information is kept strictly confidential

Claim #1   Claim Status: Closed   Open Patient Name:   Date of occurrence: Insurance Carrier:   Location of occurrence:  Allegations: Dollar Amount: Paid on your behalf: $   Reserved on your behalf: $

Claim #2   Claim Status: Closed   Open Patient Name:   Date of occurrence: Insurance Carrier:   Location of occurrence:  Allegations: Dollar Amount: Paid on your behalf: $   Reserved on your behalf: $

Claim #3   Claim Status: Closed   Open Patient Name:   Date of occurrence: Insurance Carrier:   Location of occurrence:  Allegations: Dollar Amount: Paid on your behalf: $   Reserved on your behalf: $

 

Additional Comments Please give any additional comments you feel appropriate for this premium indicator. If you have additional information where there was not enough space, please enter them here.

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