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Request Group Quote

Please complete the information below. Required fields are indicated with a red asterisk. If you are requesting a quote for coverage which is different than or separate from the work you're currently doing please provide information for the coverage you need.

* — Required fields

Group Name

Contact Information

Name

Title

Phone

Professional Website

Decision Maker Information

Name

Title

Phone

Primary Practice Location

Address

Address2

City

State

Zip Code

Practice county

Do you work in any other states?

Yes

If so, please list.

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) - Limit 2 choices

$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) - Limit 2 choices

$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

Does your group practice telemedicine?

Yes

Do you currently work with an agency/broker?

Yes

Agency

If you do not currently work with one of our contracted agencies do you give your permission to be connected with a contracted agent to facilitate your quote?

Yes

Who are the owner partners?

Pricing Information

Expiring Premium

Renewal Premium

Documentation (Limit: 10MB per file; 15MB total. To upload multiple certificates or loss runs, click "Choose Files" and select multiple files at once.)

Upload complete roster of all physicians and allied health care professionals including full names, designations, specialties, limits, and retroactive dates, if applicable

Upload current Certificate of Insurance or Declarations Page

Upload claims history reports/loss runs

Additional Comments/Requests/Procedure Information

How did you hear about us?

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