Medical Malpractice Quote
Fields marked (
*
) are mandatory.
GENERAL INFORMATION
Your Name
*
Degree
*
Please select
D.O.
M.D.
N.P.
P.A.
Your e-mail address
Primary Practice (Address, City, St, Zip)
*
Office Phone
*
Office Fax
*
CURRENT PROFESSIONAL LIABILITY COVERAGE
Current Carrier
*
Limits of Liability (Per Claim) $
Limits of Liability (Aggregate) $
Expiration Date
Retroactive Date
Current Deductible
PRACTICE INFORMATION
Check One
*
Group Practice
Individual
Average hours per week?
*
Board Certified?
*
No
Yes
Medical Specialty
*
Surgery
*
Please select
Major
Minor
None
Subspecialty or unusual procedure:
Unique practice setting:
PRACTICE HISTORY
How many claims in last 10 yrs?
*
Complete Claim History Section below for each claim!
MQAC investigations?
*
No
Yes
License suspended?
*
No
Yes
Priveleges suspended?
*
No
Yes
Claims History (if applicable)
Claim # 1
Claim Status
Closed
Patient Name
Incident Date
Report Date
Insurance Carrier
Allegations
Amount Paid on your behalf
Amount reserved on your behalf
Claims # 2
Claim Status
Closed
Open
Patient Name
Incident Date
Report Date
Insurance Carrier
Allegations
Amount paid on your behalf
Amount reserved on your behalf
Claim # 3
Claim Status
Closed
Open
Patient Name
Incedent Date
Report Date
Insurance Carrier
Allegations
Amount paid on your behalf
Amount reserved on your behalf
ADDITIONAL INFO
Best time to contact you
Afternoon
Evening
Morning
Now
Additional Comments
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