Free Evaluation

Online Information Form

Let help protect you and your practice by recommending available malpractice insurance coverage and rates, advice on safety procedures, and loss prevention protocols. has access to top-rated professional liability insurers.

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
Office Phone:

Area Code / Number

Office Fax:
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)

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:


 State  Zip

 County of Practice:

Partners in 


( 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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