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Affordable Health Care Act
 Professional Liability Quote 
Professional Liability Insurance Quote

Contact Information
Full Name:
Street Address:
Primary Practice Address
City, State & Zip: City, State & Zip:
E-Mail Address:
Best Time To Reach You:
Day Telephone:
Eve Telephone:
Fax:
Date of Birth License #:
Practice Information
Check each that applies to your practice:
Individual Partnership Association Group Practice
Professional Affiliation Other
Current Professional Liability Coverage
Current Insurance Carrier:
Limits of liability: $ per claim $ aggregate
Effective Date: Premium: $ Retroactive Date:
Professional Information
Occupation: Practice Operates: Board Certified
Specialty: Full Time
Part Time
Yes
No
Claims History
Claim #1 Claim Status: Closed Open
Claimant Name:
Date of occurrence:
InsuranceCarrier:
Locationofoccurrence:
Allegations:
Amount paid on your behalf: $
Amount reserved: $
Claim #2 Claim Status: Closed Open
Claimant Name:
Date of occurrence:
InsuranceCarrier:
Locationofoccurrence:
Allegations:
Amount paid on your behalf: $
Amount reserved: $
Claim #3 Claim Status: Closed Open
Claimant Name:
Date of occurrence:
InsuranceCarrier:
Locationofoccurrence:
Allegations:
Amount paid on your behalf: $
Amount reserved: $
Additional Comments
Please give any additional comments or questions

No coverage of any kind is bound or implied by submitting information via this online form

  • Information from you and other sources, such as your driving, claims and insurance histories, may be used to calculate an accurate price for your insurance.
  • We will not distribute information to other parties other than for insurance underwriting purposes.
  • By submitting this form, you agree to release us from any liability should this information be accidentally viewed by others.

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