Name of Practice:
Contact Person:
Phone Number:
Fax Number:
Email Address:
Street Address:
City:
State:
Zip:
Your Medical Specialty:
Do you perform surgery?
Yes
No
Are you board certified?
Yes
No
Number of years in practice:
Number hours practice/week:
Have you had malpractice claims?
Yes
No
If yes, list each:
COVERAGE NEEDS:
Proposed Effective Date:
Proposed Retroactive Date:
Proposed Liability Limits:
$200,000/$600,000
$250,000/$750,000
$500,000/$1.5 million
$1 million/$3 million
Comments: