General Information
Your Contact Information
Your Name:
Your E-Mail Address:
Website:
Information about your Practice
Primary Practice Address:
City:
County:
State:
Zip:
Office Phone:
Office Fax:
Practice Information
Individual
Partnership
Other
Group Practice
Professional Corporation
Group Practice Information
Number of doctors in practice:
Current Professional Liability Coverage
Current Insurance Carrier:
Limits of Liability:
$ per claim
$ per aggregate
Effective Date:
Claims Made
Retro Date:
Occurrence
Physician/Surgeon Information
Specialty:
Board Certified:
Yes No
Major Surgery Minor Surgery No Surgery
Claims History
Have any claims ever been made against you?
If yes, please complete the following claims supplement information sheet, or email us a loss run from your previous carriers.
Claims Detail
This information is kept strictly confidential
Claim #1
Claim Status: Open Closed
Patient Name:
Date of Occurence:
Insurance Carrier:
Location of Occurrence:
Allegations:
Amount Paid on Your Behalf:
$
Amount Reserved on Your Behalf:
Claim #2
Claim #3
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.
