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To help us get started with your professional liability analysis, please fill in the information form below.

Medical Professionals Insurance Information Form Note: Items in BOLD are required.
	Privacy Policy
Name:
Office Phone:	Area Code / Number
Office Fax:
E-Mail:
Your Specialty:
Surgery Performed:	Major Surgery Minor Surgery (Check all that apply) No Surgery Performed
Practice Hours:	Full Time (Over 20 hours per week) Part Time (20 or less hours per week)
	If OB-GYN, average number of deliveries per year:
	Year started practicing after internship and residency:
Board Certified?:	Yes No
Name of Board:	Date:
Current Carrier:
Current Coverage:
Policy Expiration:
Retroactive Date:
Years with Carrier:
Practice Name:
Office Address:
	City	State	Zip

	County of Practice:
Partners in Practice: ( list all )
Explain your unique situation and needs, i.e., Claims History Dates & Detail ( if any )

**** Please complete this form entirely. Every field is important!

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