Perfusion Professional Liability Application

The information submitted in this online quote request will not be shared or sold. We value confidentiality and your right to privacy, for this reason we will only use the information provided to secure quotes from insurance company(s) suited to this line of business. Please fill out this form as completely as possible to ensure an accurate quote.

An insurance quote does not impact your credit score.
Business Name:*
Full Name*

First NameLast Name
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
E-mail*
Date Business Was Established

MonthDayYear
Requested Limit of Insurance?
Requested Deductible
Number of Independent Contractors*
Number of Perfusionists Employed*

Underwriting Questions
Are all of the individuals licensed in accordance with applicable state or federal regulations?*

YesNo
Has the applicant or any of the employees:
Ever been the subject of disciplinary or investigative proceedings or repremand by a governmental or administrative agenc, hospital or professional association?*

YesNo
Ever been convicted for an act committed in violation of any law or ordinance other than traffic offenses?*

YesNo
Ever been treated for alcoholism or drug addiction?*

YesNo
Explain any Yes Answers

Professional Liability Premium Rating

Estimated figures may be subject to audit.
State Revenue Amounts Last Policy Year:
Fee's For Service
Other Source of Revenue
Total Gross Revenue
Number of Patient Encounters & Cases - Last Year
Esitimated Revenue Amounts This Policy Year:
Fee's For Service*
Other Source of Revenue
Total Gross Revenue*
Number of Patient Encounters & Cases - Estimated This Year*

Do you need options for:

General LiabilityPropertyGroup HealthDirectors & OfficersWorkers CompCrime CoverageCommercial AutoCyber Liability
Additional Information and Comments:
Upload Resume or CV

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By Submitting This Application:

The applicant understands that the information contained in this application will not be shared or sold and will be used for underwriting purposes only. The applicant declares that the statements and represnetation are true and correct, and that no facts have been suppressed or mistated.

Additionally, the applicant understands Lott & Gaylor Insurance products and services are not available in all states or U.S. territories and the submission of this form does not constitute a guarantee an offer of insurance. Any solicitation, negotiation, offer or sale of any insurance product or service will be predicated on the approval of the proper licensure with domiciled state in which you or your entity resides.
I understand and agree to the terms of this application.
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Underwriting Questions