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Request Group Quote

Please complete all required information on the form below:

* — Required fields

Group Name

Contact Information

Name

Tile

Phone

Professional Website

Decision Maker Information

Name

Title

Phone

Primary Practice Location

Address

Address2

City

State

Zip Code

Practice county

Are there multiple practice locations?

Yes

Policy Information

Total Number of Physicians in Group

Total number of allied health care professionals in the group

Current carrier

Is this a new start-up practice?

Yes

Policy Effective Date

Policy Type

Claims Made

Occurrence

Entity Retroactive Date for prior acts coverage?

Claims Made Limits (Amount Per Claim/Aggregate Per Year)

$100,000 / $300,000

$200,000 / $600,000

$500,000 / $1,000,000

$1,000,000 / $3,000,000

Occurrence Limits (Amount Per Claim/Aggregate Per Year)

$100,000 / $300,000

$200,000 / $600,000

$500,000 / $1,000,000

$1,000,000 / $3,000,000

Specialty

Do any physicians need Medical Director coverage for administrative or supervisory duties?

Yes

If so, who?

Are any physicians entering practice for the first time after graduate training, military, or academics?

Yes

If so, provide details

Are any physicians working part time?

Yes

If so, provide details, including who & average number of hours/week

Has the group had any claims in the past 5 years (loss runs will be required

Yes

Do you currently work with an agency/broker?

Yes

Agency

Broker's Name

Who are the owner partners?

Pricing Information

Expiring Premium

Renewal Premium

Additional Comments/Requests/Procedure Information

How did you hear about us?

Other

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