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There is no obligation in filling out a quote request form, but you stand to gain insight into our competitive rates and mission-driven style of business. Please enter your information for a non-binding premium indication. A carrier representative will respond within 24 hours. Thank you!

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Please tell us about your current insurance policy:

Current Insurance Carrier:

Policy Expiration Date (mm/dd/yyyy): *

Remember, underwriting may take up to 30 days

Physician Limits: *

Do you desire Corporate Coverage? If so, please select type:

Please tell us more about you:

Specialty: *

Types of Coverage: Claims-made Occurrence

Retroactive Date (mm/dd/yyyy): *

Medical License Number: State:

Number of Years Practicing Post-Residencey or Fellowship, Without a Paid Claim:

States Practicing In:

County Practicing In:

Are you a fellow of the American College of Surgery?: Yes No

Please list Type of Residency (e.g. General Surgery):

Please list Type of Fellowship (if applicable) (e.g. Bariatrics):

Are you a member of the American Society of Metabolic & Bariatric Surgery? Yes No

Has any insurer ever canceled, declined to issue or refused to renew your professional liability insurance, or offered insurance only on special terms, or have you been notified of such intent? If yes, please explain:

Yes No

Has any lawsuit ever been filed against you or have you been notified that any lawsuit will be filed against you alleging medical errors or omissions? If yes, please explain:

Yes No

Have any judgments been made against you, or any out-of-court settlements been made on your behalf, from an incident alleging medical errors or omissions? If yes, please explain:

Yes No

Have you ever been or are you currently under a State Board of Medical Examiners' Order? If yes, please explain:

Yes No

Have you been treated for alcoholism or drug addiction within the last five years? If yes, please explain:

Yes No

Have you ever had your license to practice medicine, to dispense narcotics, or had your hospital privelages denied, revoked, suspended, voluntarily surrendered or subject to probationary terms for any reason including competency or conduct? If yes, please explain:

Yes No

Physician Name: *

Contact Name: *

Corporation/Practice Name: *

Address: *

City * State: * Zip Code *

Phone: *

Fax: *

Email: *

How do you wish to be contacted? (check all that apply):
Mail Phone Email Fax

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