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 Medical Malpractice Quote 
Medical Malpractice Quote
Contact Information:
First Name:
Last Name:
Daytime Telephone:
Evening Telephone:
Email:
Address:
City:
State:
Zip:
Practice Information:
Location Address:
How Long At This Location:
Check each of the following that applies to your practice: Individual Group Practice Partnership
Professional Corporation Association Affiliation
Other:
Number of physicians in group 2-4 5-8 9+
If in a group practice, is the group owned, managed or controlled by any other healthcare entity? Yes No
If "yes", name the entity and the relationship:
Current insurance carrier
Limits of Liability: $ - $
Deductible: $
Renewal Date: / /
Premium: $
Per Quarter:$ or Annually: $
Retroactive Date:
My desired effective date for
Medical Malpractice insurance is
Desired limits
(Check all you want quotes for)		 $1,000,000 - $3,000,000
$2,000,000 - $4,000,000
$5,000,000
Other $ - $
Number of employed Physician Assistants/Nurse Practitioners
Physician/Surgeon Information:
Specialty: Full Time Part Time
Years Experience in Specialty:
Years Practicing in Community:
Board Certified? Yes No
Any previous claims activity? Yes No
If yes, Doctor Name:
Date of Claim: / /
Patient Name:
Status: Open
Closed Claim
Settlement
Judgment
Dismissal
If Open, Reserve Amount: $
If Closed, Amount Paid: $
Defense Costs: $
Comments or Questions:
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