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Quick Quote Request

All fields marked with a red * are required.

1. First Name: *
2. Last Name: *
3. Medical Designation: *
4. Medical Specialty: *
5. Medical Subspecialty (please specify or input N/A): *
6. Are you ABMS American Board Certified? *
7. Do you practice Full Time or Part Time? *
8. Date of Birth: *
9. Primary practice location - street address: *
10. County, Parish or Borough that the practice is located in: *
11. City: *
12. State: *
13. Zip Code: *
14. Primary Contact Phone Number: *
15. Primary Contact Email Address: *
16. What best describes your medical practice setting? *
17. Do you or the medical practice have a registered legal entity such as a Corporation, LLC or Other? *
18. Name of Entity as it appears on your Articles of Incorporation (or input N/A): *
19. Are there any Ancillary Medical Staff EMPLOYEES or Independently CONTRACTED Medical Practitioners who will need to be insured under your Malpractice policy? *
20. Please provide your medical practice Web Site address (or input N/A): *
21. Current Malpractice Insurer: *
22. How many CONTINUOUS years have you been insured by your CURRENT Malpractice Insurance Company? *
23. Current Malpractice Policy Expiration Date: *
24. Current Malpractice Policy Retroactive Date: *
25. If you did not provide a Retroactive date does that mean you are on an Occurrence policy now? *
26. Limits of Liability that you are requesting: *
27. In the past 10 years have there been any times at which you were not actively practicing medicine or not actively insured or had ANY gaps in Malpractice Insurance Coverage? *
28. Have you experienced any CLAIM PAYOUTS or CLAIM SETTLEMENTS within the past 10 years? *
29. Are you or any member of your practice (for whom you have collaborative or supervisory responsibility) performing any of the items shown in PART 2 below? *
29. PART 2:
Employed or Contracted as a Medical Director?
Employed or Contracted by a Nursing Home or LTC facility?
Employed or Contracted by a Correctional Facility?
Employed or Contracted by a Methadone Clinic?
Employed or Contracted by an Abortion Clinic?
Performing Abortions either by surgical or medicinal means?
FP or GP performing 1st, 2nd or 3rd trimester prenatal care?
Performing VBAC's or High Risk Deliveries?
Performing Cosmetic / Aesthetic / MedSpa procedures?
Performing Tumescent Lipo or any other type Liposuction?
Performing Suture Suspension Face Lifts / Contour Thread Lifts / Feather Lifts?
Weight Control by prescribing or administering of medications?
Hormone Replacement Therapy by prescribing or administering of medications?
Performing Naturopathic or Homeopathic medicine?
Performing Acupuncture or Acupressure?
Performing MUA's (Manipulation Under Anesthesia)?
Performing Lap Band procedures for weight control?
Performing Pain Management procedures or prescribing of Pain Medications?
Performing Sex Change operations or Penile Implants?
Performing procedures or administering medications not approved by the FDA?
Performing procedures not customary to your Residency or Fellowship training?
Performing Telemedicine or Telehealth services? (other than Teleradiology)
Working in the ER? (other than for maintaining your hospital privileges)
Employed or Contracted as a Hospitalist?
Please provide any additional info or details regarding your practice or insurance needs  here:
As applicant, please type in your full name here: *
Consent Agreement - your check mark in the box means you agree. *
As applicant named above I agree to allow this information to be used for the purpose of a pre-qualification quote analysis. I understand that the information I am providing may be shared with other parties but strictly and only for the purpose of determining Medical Professional Liability Insurance eligibility and preliminary pricing.
Please enter the date you completed and submitted the QUICK QUOTE form: *

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