Baxter Insurance Pensacola Florida

Name of Practice:
Contact Person:
Phone Number:		Fax Number:
Email Address:
Street Address:
City:		State: Zip:
Which describes your practice?
Number of years in practice:
Number hours practice/week:
Have you had malpractice claims?		Yes No
If yes, list each:
COVERAGE NEEDS:
Type of Coverage:		Claims-made Occurence Both
Proposed Effective Date:
Proposed Retroactive Date*:		*claims-made only
Proposed Liability Limits:		$100,000/$300,000 $200,000/$600,000 $250,000/$750,000 $300,000/$900,00 $500,000/$1.5 million $1 million/$3 million Other:
Comments: