Medical Malpractice Form

1

What can we help you with?* This field is required.

Medical malpractice insurance

Tail malpractice coverage

Cyber coverage

RAC audit

Business coverage

Property coverage

Employee health benefits & insurance

Workers' compensation

I'm not sure...

2

Name of Practice?* This field is required.

3

Practice Location?* This field is required.City, State

4

Category of Practice* This field is required.

Physician solo practice

Physician group

Hospital

Nursing home

Multi-specialty clinic

Ambulatory surgery center

Outpatient clinic (i.e. free clinic, cancer treatment, dialysis clinic, etc.)

Other

5

What is your specialty? Please describe your practice* This field is required.

6

Do you have a website? If so, please enter it below:

7

Current professional liability insurance carrier:

8

Is your current policy claims made or occurrence?

claims

occurrence

9

Current policy expiration date:

10

Name

First Name

Last Name

11

What phone number should we call if we have questions?* This field is required.

Area Code

Phone Number

12

What is your email address?* This field is required.

13

Do you have a preferred contact method?

Phone

Email

Doesn't matter