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| Fields marked (*) are mandatory. |
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| GENERAL INFORMATION |
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| Your Name* |
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| Degree* |
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| Your e-mail address | |
| Primary Practice (Address, City, St, Zip)* |
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| Office Phone* |
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| Office Fax* |
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| CURRENT PROFESSIONAL LIABILITY COVERAGE |
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| Current Carrier* |
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| Limits of Liability (Per Claim) $ | |
| Limits of Liability (Aggregate) $ | |
| Expiration Date | |
| Retroactive Date | |
| Current Deductible | |
| PRACTICE INFORMATION |
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| Check One* |
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| Average hours per week? * |
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| Board Certified?* |
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| Medical Specialty* |
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| Surgery* |
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| Subspecialty or unusual procedure: | |
| Unique practice setting: | |
| PRACTICE HISTORY |
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| How many claims in last 10 yrs? * |
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| Complete Claim History Section below for each claim! |
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| MQAC investigations?* |
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| License suspended?* |
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| Priveleges suspended?* |
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| Claims History (if applicable) |
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| Claim # 1 |
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| Claim Status | |
| Patient Name | |
| Incident Date | |
| Report Date | |
| Insurance Carrier | |
| Allegations | |
| Amount Paid on your behalf | |
| Amount reserved on your behalf | |
| Claims # 2 |
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| Claim Status | |
| Patient Name | |
| Incident Date | |
| Report Date | |
| Insurance Carrier | |
| Allegations | |
| Amount paid on your behalf | |
| Amount reserved on your behalf | |
| Claim # 3 |
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| Claim Status | |
| Patient Name | |
| Incedent Date | |
| Report Date | |
| Insurance Carrier | |
| Allegations | |
| Amount paid on your behalf | |
| Amount reserved on your behalf | |
| ADDITIONAL INFO |
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| Best time to contact you | |
| Additional Comments | |
| Thank You for Completing Our Online Quote Request! Click Submit to Send |
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